.i9 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


THE 

Pathology,  Diagnosis,  and  Treatment 

OF   THE 

Diseases  of  Women 


BY 

GRAILY  HEWITT,  M.D.Lond.,  F.R.C.P. 

PROFEJSOR    OF  MIDWIPEKV  A.NMl  DISEASES  OF  WOMEN,  VNIVEHSITV    COLLEGE.  AND   ODSTBTRIC 

fHVSlCIAN     TO     THE     HOSI'll  AL  ;      FOKMKRLV    I'REMDEST   OF   THE     OBSTETRICAL 

SOCIETY  OF  LONDON  ;  HONOHARV  FELLnV  OF  TUB  OBSTBTRICAL  SOCIKTY 

OF     BERLIN  ;     HONORARY     FELLOW     OF     THK     CYN/CKHLuCICAL 

SOCIETV     OF     U"ST>N;      Hi.NORAKY      FELLOW     OF    THE 

MEDICAL   SOCIETV    OF   HELSINCFOKS 


A  New  American  from  the  Fourth  Revised  and  Enlarged  London  Editir^ 
With  236  Illustra  ions 


Edited  with  Notes  and  Additions 

BY 

HARRY    MARION-SIMS,    M  D. 

Attending  Surgeon   to   St.   Elizabeth's   Hospital,  New  York,  Etc 


VOLU  ME      I 


NEW  YORK 

BERM  INGHAM    &    CO. 

1S83 


Copyright.  188-'5.  bj-  Bermingham  &  Co. 


Liknn 

KJP 
EDITOR'S    PREFACE. 


The  autlior  sent  the  proof-shceis  of  this  edition  of  his 
book  to  me  with  the  request  that  I  would  supervise  their 
passage  through  the  press,  and  add  any  notes  I  might 
clioose  to  make.  Having  known  him  from  my  early  boy- 
hood, I  accepted  tlie  compliment,  and  determined  to  give 
the  book  the  widest  circulation  possible. 

The  book  has  some  points  of  peculiar  interest.     It  insists 
on  better  nutrition.     It  advocates  the  mechanical  pathol- 
ogy of  some  forms  of  uterine  disease,  viz.,  that  pathologi- 
cal   changes   are    produced    by   mechanical    causes.       The 
wood-cut  illustrations  of  uterine   displacements  are  of  life 
size,  which  is  an  aid  to  the  beginner.     We  have  long  known 
that  the  nausea  of  pregnancy  is  a  neurosis,  a  refie.x  symp- 
tom  which   the  author  shows  very  conclusively  to  be  the 
result   of  some  form  of  uterine   distortion,  and   which    is 
Nq^   always  relieved  by  appropriate  mechanical  treatment.     He 
N^    further  demonstrates   most    satisfactorily   that  hysteria  in 
V     all  its  protean  forms  is  a  uterine  refle.x  symptom  (not  ovari- 
y*    an  as  has  been  generally  supposed),  dependent  always  on 
fle.xion  or  malposition;  and  that  to  remedy  the  latter  is  to 
cure  the  former. 
Ni        This  book  has  many  other  features  of  interest,  which  the 
'     student  will  readily  appreciate. 

The  notes  I  have  added  are  embraced  in  brackets  in  the 
text. 

Harry  Marion-Sims. 
267  Madison  Ave.,  New  York,  April,  1883. 


ti2^2'j5 


PREFACE 

TO 

THE    1-OURTII    EDITION. 


Ten  years  liave  elapsed  since  the  last  edition  of  this  woriv 
was  pul)lishe(i.  What  I  have  gained  from  observation  ana 
experience  during  those  ten  years  has  been  here  faithfuliv 
ana  truly  set  down. 

In  the  last  edition  of  this  work  I  endeavored  to  enunciate 
and  demonstrate  certain  general  principles  as  to  the  pathol- 
ogy of  diseases  of  the  uterus,  more  especially  to  show  that 
ihe  changes  in  the  shape  and  position  of  the  uterus  are 
directly  or  indirectly  responsible  for  the  sufferings  and  dis- 
comforts attendant  on  the  affections  peculiar  to  the  female 
sex.  The  conclusions  expressed  ten  years  ago  have  been 
tested  and  vcritictl  by  subsequent  experience;  and  additional 
facts  and  observations  on  this  subject  will  be  found  in  this 
volume. 

I  have,  however,  in  the  present  edition  advanced  a  step 
further,  and  have  explained,  to  my  own  satisfaction  at  all 
events,  how  and  why  it  is  that  changes  in  the  shape  and 
position  of  the  uterus  are  so  liable  to  occur:  what,  in  short, 
are  their  predisposing  causes.  An  extended  experience 
has  enablefl  me  to  submit  a  further  and,  as  I  consider,  a 
most  important  generalization  on  the  subject.  What  I 
have  to  say,  in  fact,  amounts  to  this,  that  alterations  in  Uie 
shape  and  position  of  the  uterus  are  rarely  witnessed  ex- 
cept in  individuals  whose  general  strength  has  become 
seriously  impaired  by  a  systematic,  and  often  a  lengthenea, 
practice  of  taking  little  food.  The  term  "chronic  starva- 
tion" appropriately  designates  this  condition;  and  a  long 
course  of  observations  has  convinced  me  that  it  is  a  most 
important  factor  in  the  production  of  the  class  of  diseases 
above  alluded  to. 


VI  PREFACE   TO    THE   FOURTH    EDITION. 

These  considerations  are  fundamental  in  regard  to  the 
subject  of  the  pathology  of  the  uterus,  and  they  underlie 
all  that  is  to  be  said,  or  that  can  be  said,  on  the  matter. 
In  the  present  work,  much  attention  l.as  been  bestowed  on 
the  development  and  application  of  the  above-mentioned 
principle,  which  is,  of  course,  nothing  more  or  less  than 
this — the  dependence  of  local  ailments  on  general  ones.  If 
there  be  nothing  ver}^  novel  in  this  doctrine,  it  may  be  at 
all  events  of  some  service  to  give  it,  in  a  more  precise  man- 
ner than  has  hitherto  been  attempted,  a  definite  application 
to  the  class  of  maladies  treated  of  in  this  work. 

The  question  as  to  the  nature  of  Hysteria  and  Hystero- 
epileps)^  has  much  occupied  my  attention,  and  the  present 
volume  contains  a  collection  of  observations  on  the  sub- 
ject, together  with  deductions,  which  I  submit  to  the  candid 
and  dispassionate  consideration  of  my  readers. 

An  important  class  of  cases  are  those  in  which  Pregnancy 
is  associated  with  Flexion  of  the  Uterus.  This  is  a  subject 
of  great  interest,  as  also  a  cognate  one,  viz.,  the  cause  of 
the  Vomiting  of  Pregnancy.  In  the  present  volume  will 
be  found  essays  on  these  subjects,  and  an  accumulation  of 
evidence  in  the  shape  of  cases  in  proof  of  the  truth  of  the 
doctrines  I  some  years  ago  enunciated  on  this  latter  ques- 
tion. 

A  considerable  number  of  new  illustrations  have  been 
added  to  the  new  edition;  and  most  of  the  new  figures 
representing  flexions  and  displacements  of  the  uterus  are 
drawn  life  size,  and  the  various  mechanical  appliances  for 
their  treatment  are  drawn  the  actual  size  of  the  instru- 
ments, with  the  view  of  rendering  the  descriptions  and 
directions  for  treatment  more  explicit  and  less  liable  to 
misinterpretation. 

The  greater  part  of  this  new  edition  has  been  re-written. 

G.  H. 

36  Berkeley  Square,  October,  18S2. 


CONTENTS   OF  VOL.   I. 


CHAPTER   I. 

GENERAL  CONSIDERATIONS   RESPECTING  THE   DISEASES  OF   THE   SEXUAl- 
ORGANS    IN    WOMEN. 

Relations  Subsisting  between  General  and  Local  Diseases. — Ira 
portance  of  Maintenance  of  proper  Nutritional  Power  as  aflcciing  thf 
General  Condition  of  the  Patient — Nutritional  Weakness  of  the  Uteruf 
a  Cause  of  Softness  of  the  Uterus,  and  an  Important  Factor  in  causing 
other  Diseases  of  the  Organ — Relative  Importance  of  Affections  of  tht 
Uterus  and  the  Ovaries P^^'^  32 

CHAPTER   II. 
NATURAL   HISTORY   OF   THE   UTERUS   AND   OVARIES. 

Natur.'M.  History  of  the  Uterus. — Effects  of  Menstruation — Preg- 
nancy— Sexual  Intercourse. 

OvARiF.s  :  Phknomena  of  Menstruation  and  Ovulation. — Vascular 
and  Erectile  Apparatus  of  Female  Sexual  Organs:  Bulb  of  the  Vagina: 
Bulb  of  the  Ovary — .Mechanism  of  Ovulation  —  Rougei's  Researches — ■ 
Menstruation — Recent  Researches  by  Kundrat.  En>;clmann,  VVilliami 
and  Leopold  as  to  the  Nature  of  Menstruation — Source  of  the  Blood- 
Phenomena  observed — .Age — Periodicity,  Duration,  Quantity,  and 
Quality  of  the  Discharge yj 

CHAPTER   III. 
examination  of  the  uterus  and  ovaries. 

Digital  Examination  of  the  Uterus  from  the  Vagina. — Position  of 
the  patient. 

DoiRLE  Examination  of  the  Uterus. 

Digital  Examination  of  the  Os  Uteri  and  of  the  Vaginal  Part 
of  the  Cervix  Uteri. — Normal  Condition  of  the  Os  and  Cervix — 
Method  of  Examination — Apparent  Absence  of  the  Os  Uteri;  various 
Causes — Unusual  Softness  of  the  Os  Uteri  from  Pregnancy  or  other 
Causes — Unusual  Hardness  of  the  Lips  of  the  Os  Uteri;  its  Causes — 
Size  of  the  Os  Uteri — Variations  in  the  Length  of  the  Vaginal  Portion 
of  the  Cervix  Uteri;  Relation  of  Pregnancy  to  this  Condition. 

Examination  of  the  Uterus  by  Means  of  the  Sound. — The  Instru- 


8  CONTENTS   OF  VOL.   I. 

ment;  Method  of  Introduction — Variations  in  the  Length  and  Direction 
of  the  Uterine  Canal  detected  by  the  Sound. 

Examination  of  the  Os  Uteri  py  Means  of  the  Speculum. — General 
Rules— Method  of  Using  the  Instrument — Description  of  Various  In- 
struments. 

Examination  of  the  Ovaries 60 

CHAPTER  IV. 

symptomatology  of  diseases  of  the  uterus. 

List  of  Symptoms  Observed. — Uterine  Dyskinesia,  its  Importance  and 
Frequency — Hysterical  Symptoms — Cerebral  Symptoms 91 

CHAPTER  V. 

.   general  pathology  of  the  uterus. 

Historical  Summary. — The  Mechanical  System  of  Uterine  Pathology 
— Definition — Laceration  of  the  Cervix  Uteri 94 

CHAPTER  VI. 

abnormal  conditions  of  the  tissues  of  the  uterus — mal-nutrition 
of  the  uterus — abnormal  softness. 

Mal-nutrition  of  the  Uterus  or  Abnormal  Softness. — Its  true 
Pathological  Nature — Evidence  of  Existence  of  General  Mal-nutrition 
in  such  Cases — Effects  in  Predisposing  to,  or  Causing  Distortions  of, 
the  Uterus — Symptoms  observed — Typical  Cases 100 

CHAPTER  VII. 

congestion  of  the  uterus  and  congestive  hypertrophy. 

Peculiarities  of  the  Circulation  of  the  Uterus. — Effect  of  Com- 
pression at  the  Centre  of  the  Uterus  in  producing  Congestion  at  its 
Two  Extremities — General  Congestion  :  Causes — Acute  and  Chronic 
Varieties — Relation  of  Acute  Form  to  Gooch's  "Irritable  Uterus" — 
Effect  of  Flexions  in  causing  Acute  Congestion — Chronic  Congestion: 
Causes  and  Effects — Increase  in  Size  of  Uterus — Association  of  Chronic 
Congestion  wiih  Flexions no 

CHAPTER  VIII. 

sub-involution  of  the  uterus — atrophy  and  hypertrophy  of 
the  uterus. 

Sub-involution  of  the  Uterus. — Nature  and  Treatment. 

Atrophy  of  the  Uterus  ;  the  Result  of  Sexual  Involution— Premature 

Senile   Atrophy    or    "Super-involution"    of   the    Uterus — Mechanical 

Atrophy. 
Hypertrophy  of  the  Uterus.  — Result  often  of  Defective  Involution 

after  Delivery — Hypertrophy,  with  Elongation  of  the  Cervix....     121 


CONTENTS   OF   VOL.    I.  Q 

CHAPTER  IX. 

TREATMENT  OF  THE  VARIOUS  TEXTURAL  DISORDERS  OF  THE  UTERIS — 
MAL-NUTRITION  OF  THE  UTERUS— CONGESTION,  CONGESTIVE  HVPER- 
TRiJl'HV,    ETC. 

General  Preveniive  Treatment — Dietary  Necessani' — Importance  of  De- 
ficient Dietary  as  a  Cause  of  Uterine  Disease — Defects  ^Qualitative  and 
Quantitative — ■"Chronic  Starvation"  a  Real  Disease — Its  Importance — 
Method  of  Dealing  with  it — Preveniive  Treatment  as  refjanls  Menstru- 
ation—  Preventive  Treatment  in  Child  bed — CorResiion  of  the  Uterus 
and  Confjesiive  Hypertrophy — General  Treatment — By  Alterinjj  Posi- 
tion and  Shape  of  Uterus — By  Leeching.  Scarifications,  etc. — Use  of 
Hot-water  Injections — Baths  and  Waiering  places — .\siringent  and 
Caustic  Applications  to  the  Os  Uteri — Internal  Remedies 123 

CHAPTER  X. 

ABNORMAL   CONDITIONS   OK   THE   LINING   OF   THE   UTERUS. 

General  Employment  of  Term  Endometritis  —  Explanation  of  these  Cases 
— Cause  most  frequently  Retention  in  Uterine  Cavity  of  Irritating 
Discharges,  Retention  being  due  to  Uterine  Distortion — Importance  of 
Drainage  of  Uterine  Cavity — Fungous  Condition  <>(  the  Lining  of  the 
Body  of  the  Uterus  shown  to  be  really  Congestive  Hypertrophy  of  the 
Mucous  Membrane 144 

CHAPTER  XL 

ACUTE  INKLA.MMATKiN  OF  THE  UTERUS. 

Nature  and  Treatment 153 

CHAPTER  XII. 

DEFECTIVE   DEVELOPME.NT   OF   THE   UTERUS — CONGENITAL   MALFORMA- 
TIONS. 

Diagnosis. 

List  of  Cases. — Absence  of  Rudimentarj-  Formations  of  the  Uterus — 
Infantile  Uterus — Uterus  Unicornis — Double  Uterus — Absence  of  the 
Os  Uteri 155 

CHAPTER  XIII. 

DISPLACE.MENTS,    DISTORTIONS    (FLEXIONS)  OF    THE    UTERUS — I.    NORMAL 
SHAPE,    POSITION,    AND   MOVEMENTS   OF   THE   UTERUS. 

Normal  Shape,  Position,  and  Movements  of  the  Uterus. — Form  and 
Shape,  how  preserved  in  a  State  of  Health — The  Proper  Position  of 
the  Uterus:  Discussion  of  various  Opinions  on  the  Subject:  Schultze, 
Schrocder,  De  Warker.  etc. — Conclusion  arrived  at — Normal  Move- 
ments of  the  Uterus — Decree  of  Fi.xation  of  the  Uterus — Motions  De 
scribed  ;  I.  Descent  ;  2.  Rotation  on  Transverse  Axis  ;  3.  Flexion — 
Effect  of  Evacuation  of  Contents  of  Bladder  considered 161 


id  CONTENTS   OF   VOL.   I. 

CHAPTER  XIV. 

DISPLACEMENTS,    DISTORTIONS   (FLEXIONS)  OF  THE   UTERUS — 
2.    PATHOLOGY   AND    GENERAL   HISTORY. 

Nomenclature — Flexion,  Distortion,  Version,  Prolapsus — Complex  Na- 
ture of  Cases — Frequency  of  Distortions  and  Displacements — Statistics 
from  Author's  Hospital  Practice — Statistics  from  Private  Practice.     174 

CHAPTER  XV. 

DISPLACEMENTS   AND   DISTORTIONS   OF   THE   UTERUS   (FLEXIONS) — ' 
3.    ETIOLOGY. 

Etiology. — Statistics  of  Cases  in  Private  Practice,  showing  Frequency 
of  Mechanical  or  Physical  Injury  or  Accident. 

Ci  ASSIFICATION  OF  Calses.  —  I.  Predisposing:  Undue  Softness  of  the 
Uterus  from  Mal-nutri'.ion  (Chronic  Starvation) — from  Sub  involution 
— Physical  Prostration — Rupture  of  Perineum — Previous  Pregnancy 
— 2.  Exciting:  Accidents — Over-exercise — Special  Exercises — Special 
Occupations — Marriage — 3.  General  Causes 179 

CHAPTER  XVI. 

DISPLACEMENTS   AND   DISTORTIONS   OF   THE  UTERUS   (FLEXIONS) — 
4.    CLASSIFICATION   AND   PATHOLOGICAL   EFFECTS. 

Classification  of  Flexions  and  Consequent  Displacements. — Patho- 

locical  Effects. 
I.  The  Seat  of  the  Flexion;  2.  Variations  in  the  Condition  of  the  Tissues 

of  the  Uterus;  3.    Various  Kinds  of  Flexion  or  Version  (Rotation);  4. 

Varieties  in  Position  of  Uterus  as  a  Whole. 
Pathological  Effects  of  Flexions,  Relation  to  Congestion,  Relation 

to  Hypertrophy  of  the  Uterus— Contraction  of  the  Cervical  Canal — 

Changes  in  the  Uterus,  Atrophy,  Compression  at  the  Seat  ot  the  Bent. 

Sensitiveness  at  the  latter  Spot — Persistence  of  the  Distorted  Shape  of 

the  Uterus — Changes  at  the  Os  Uteri 188 

CHAPTER  XVII. 

displacements   and   distortions   of   THE   UTERUS   (FLEXIONS) — 
5.    SYMPTOMS,    INCLUDING   STERILITY   AND   ABORTIONS. 

Pain,  Spontaneous— Pain  on  Locomotion  (Uterine  Dyskinesia)— Explana- 
tion of  this  Symptom  :  Its  Great  Importance — Undue  Tenderness  of 
the  Uterus  to  Touch — The  "  Irritable  Uterus"  of  Gooch  shown  to  be 
Acute  Flexion. 

Dysmenorrhoea.  Leucorrhoea,  Menorrhagia,  Amenorrhcea — Sterility — 
Aboriions — Statistics  of  Sterility  and  Abortions  in  Hospital  and  Pri- 
vate Practice. 

Disturbance  of  Functions  of  Bladder— of  Rectum — Dyspareunia — Reflex 
Nervous  Symptoms loy 


CONTENTS   OF  VOL.   I.  II 

CHAPTER  XVIII. 

Displacements  and  distortions  of  the  uterus  (flexions) — 
6.  general  principles  of  treatment. 

t*RlNCiPi.ES   OF   Treatment. — i.   Indications — Restoration   of    General 

Sirenpth;  2.   Restoration  of  Uterus  to  Proper  Shape  and  Position. 
Difficulties  Encdunterkp. — Question  of   Necessity  for  Examination 

—  Definition  of  General  and  Local  Treatment — Curability  of  Flexions 
— \'arious  Causes  of  Difficulty. 

General  Treatment. — Restoration  of  Nutritional  Power  and  Activity 
— Rest,  how  to  be  carried  out — Utilization  of  Intluciicc  of  Gravity — 
Attention  to  Condition  of  Bowels. 

L'TAL  Treat.ment. — Positional  or  Postural  Treatment — Prone  Kneel- 
ing Position — Horizontal  Position.  Use  of  the  Sound  repeatedly — 
Cases  adapted  for  it.  Use  of  Sound  combined  with  Dilatation  of  Cunal 
by  Means  of  a  Dilating  Sound.  Treatment  by  Means  of  Stems:  Cases 
requiring  it — Its  Value  and  .Aprlicabiliiy.  Use  of  Tents.  Incision  of 
the  Uterine  Canal.  Vaginal  IVssaries — General  Method  of  Action — 
Cases  suitable  for.  Necessity  for  conjoint  Postural  Trcatmenl  and 
Use  of  Sound.  Other  Requirements  when  Vaginal  Pessaries  are  em- 
ployed. Material  of  Vaginal  Pessarit-s.  General  Summary.  Pallia- 
tive Treatment.  Use  of  Hot-water  Injections.  Opiates.  Treatment 
of  the  Accompanying  Ctmgestion 224 

CHAPTER  XIX. 

RETROFLE.XION  AND  RETROVERSION  OF  THE  UTERUS. 

Severity  of  the  Affection — Curability. 

Frequency — In  Hospital  and  Private  Practice — Compared  with  Ante- 
flexion— Single  or  .Married. 

Special  Causes — Traumatic  Influences — Dr  .Squarcy's  Views — Influence 
of  Bladder — Pregnancy — -Strainmg  ElToris  in  Dofiec.ilion. 

Varieties — Basis  for  Classification.  i.  Degree  of  the  Flexion,  first, 
second,  third  ;  2.  The  Degree  of  \'ersion  (Rotation) — Substitution  of 
Word  "Rotation"  for  \'ersion — Degrees,  one,  two  and  three;  3.  De- 
gree of  Descent  of  Uterus  as  a  Whole  ;  4.  Degree  of  Resistance  to 
Replacement  and  Unbending  ;  5.  Degree  of  Congestion  and  Enlarge- 
ment. 

Progress. 

Complications — Adhesions — Congestion — Not  to  be  Confounded  with 
Rigidity — Prolapse  of  Ovary — Rupture  of  Perineum — Fibroid  Tumor 

—  Prolapsus  of  Rectum. 

Symptoms — Pain,  Dysmenorrhoea.  Menorrhagia,  Leucorrhoca.  Amenor- 
rhoea — Sterility — Abortions — Derangements  of  BladJer,  of  Rectum — 
Reflex  Disturbances. 

Diagnosis 242 

CHAPTER  XX. 

RETROFLEXION   AND   RETROVERSION    OF   THE    VTEKVS— {Continued). 

Treatment. — General — Local — Plan  recommended — Outline  and  Details 
— Postural  Treatment — .Mechanical   Direct    Reposition — Maintenance 


12  CONTENTS  OF  VOL.   I. 

of  Proper  Position  by  Vaginal  Pessary — Form  of  Pessary  recom- 
mended— Various  Sizes  required. 
Position  of  Patient — Use  of  the  Sound — Conjoint  Use  of  Sound  and  Pes- 
sary— Difficulties  encountered  in  Treatment  of  Cases — Adjustment  of 
Size  of  Pessary — How  far  Vaginal  Pessaries  are  reliable — Action  of 
the  A.  Smith  Modification  of  Hodge  Pessary — Necessity  for  Rest,  and 
Gradual  Elevation  of  Fundus  in  some  Cases — Occasional  Over-action 
of  the  Retroflexion  Pessary — How  long  to  be  continued — Method  ot 
Introduction — Change  of  Pessary — Various  Modifications  of  Retro- 
flexion Pessary — Dilatation  and  ]\Ioulding  for  Cure  of  Retroflexion — 
Stem  Pessary — Incision  and  Immediate  Rectification — Radical  Opera- 
tion (Koeberle) — Oophorectomy 262 

CHAPTER  XXI. 
anteflexion  and  anteversion  of  the  uterus. 

Importance  of  Anterior  Displacements  and  Flexions  Considered. 
— Frequency  with  which  these  Conditions  give  Rise  to  Uterine  Dys- 
kinesia— Great  Frequency  of  this  latter  Symptom  as  observed  in  Prac- 
tice. 

Definition. — Difficulty  hitherto  Experienced  in  Definition — Owing  to 
Existence  of  slight  Anteflexion  in  Normal  Uterus — Owing  also  to  Mis- 
apprehension of  True  Nature  of  Congestion  of  Uterus  associated  with 
Anteflexion — Author's  Definition:  Exceptional  Cases  when  the  Defini- 
tion does  not  apply — Use  of  the  Finger  in  making  the  necessary  E.x- 
ploration — Precautions  to  take. 

Frequency. — Hospital  and  Private  Practice  compared — Single  or  Mar- 
ried— Age  of  4S8  Cases  in  Private  Practice. 

Etiology. — Predisposing  Causes — Discussion  of  Schultze's  Views  as  to 
Movement  of  Uterus  when  Bladder  is  emptied — Author's  Dissent  from 
Schultze's  Conclusions — Importance  of  Softness  of  Uterine  Tissues 
and  Want  of  Rigidity  as  causing  Anteflexion — Previous  Pregnancy — 
Rupture  of  Perineum — General  Physical  Weakness  and  Prostration — 
Special  or  Exciting  Causes:  Traumatic  Causes,  their  great  Frequency 
— Previous  Attacks  of  Parametritis— Schultze's  "Pathological  Ante- 
flexion"— General  Perimetric  Fixation  result  of  Anteflexion  of  long 
standing 286 

CHAPTER   XXII. 

anteflexion  and   ANTEVERSION  OF   THE   VTERVS—{Ccy>lfi/llH-J). 

Varieties— I.  In  Degree  of  Flexion;  2.  Degree  of  Rotation  of  Uterus; 
3.  Degree  of  Descent  of  Uterus  as  a  Whole;  4.  Rigidity  of  Uterine 
Tissues — Various  Combinations  of  these  possible,  hence' Infinite  Dif- 
ferences in  Cases— Three  Principal  Degrees  of  Flexion— Some  Lead- 
ing Types  Described— Various  Conditions  of  Cervix— Anteflexion  with 
Posterior  Rotation— Severe  Cases  in  which  the  Uterus  is  very  low 
down,  compressing  the  Recium— Variations  in  Rigidity  of  Uterine 
Tissue  and  Connections— Clinical  Features  of  Different  Cases— Illus- 
trative Cases  given— Degree  of  Congestion  present. 

Complications.- Congestion,  Accessions  of  Acute  Congestion— Disten- 
sion of  Cavity— Adhesions— Cystocele— Cystitis— Constipation. 


CONTENTS   OF  VOL.   I.  1 3 

Symptoms — Uterine  Dyskinesia — Illustrative  Facts  In  Refjard  to  this  ob- 
served  in  Thirty-three  "  Fertile"  Women  and  in  Thirty-five  Single 
Cases — Spontaneous  Fain — Tenderness  of  Uterus  to  Touch — Other 
Abnorm.il  Sensations  —  Dysmenorrha-a.  Menorrhagia.  Lciicorrhcca. 
AtDcnorrhoca —  Sterility —  Abortions  —  Dysparcunia — Reflex  Nervous 
Symptoms — Symptoms  referable  to  Bladder;  to  Rectum. 

Diagnosis. — Various  Difficulties— Method — Use  of  Sound — Precautions 
and  Difficulties  in  introducing  it  in  Diflcrcnt  Cases 29S 


CHAPTER    XXill. 
ANTEFLEXION   AND   ANTEVERSION   OF  THE  UTERUS — {ConHttUfd). 

Treatment. — Important  DifTcrcntiation  of  Cases  in  rejjard  to  Cause  of 
the  Affection — The  A^e.  the  Duration  of  the  Malady — lmpr>rtancc  of 
General  Treatment — Illustrations  of  Method  of  Treatment  necessary 
in  a  Recent  Case — Positional  Treatment  %'ery  Important;  How  to  be 
carried  out — Sittinp  Position  to  be  avoided — A  more  Severe  Case^ 
Combination  of  Local  and  General  rrcatineiit — Use  of  "Cradle"  Pes- 
sary and  Sound — Case  in  which  Uterus  is  very  Rigid  and  Affection  of 
some  standing — Further  illustrative  Cases  of  Treatment  of  Anteflexion 
after  Pregnancy. 

Employment  of  "  Incisions"  of  the  Cervix — Former  Misconceptions  as 
to  Stricture  of  the  Cervical  Caral  —  Utility  of  the  Operation  in  Cases 
of  Flexions  considered  —  Neressity  for  Uougies  or  Stems  afterward  — 
The  "  Stem"  Treatment  considered — General  Conclusions — Difficulties 
in  Absolute  Cure  of  Long-standing  Ca,scs 324 

CHAPTER   XXIV. 

ANTEFLEXION   AND   ANTEVERSION   OF   THE  t'TERCS — {ContittUfd). 
TREATMENT — (<-i>/l //««<•/). 

Pessaries  for  the  Treatment  of  Anteflexion  and  Anteversion. — 
The  Author's  "Cradle"  Pessary — Principle  of  Its  Action — Two  Vari- 
eties, the  "Bar  Cradle"  and  "Crutch  Cndlc"  —  Various  Sizes  re- 
quired— Various  Materials — Modificati'in  in  Usr  resembling  Gehrung's 
Pessary — Introduction  and  Removal  of  the  Cradle  Pessary — Precau- 
tions in  Regard  to  its  Use — Dr.  Gaillard  Thomas's  Pessaries — Other 
Pessaries:  Playfair's,  Galabin's,  Fancourt-Barnes's,  Gallon's — The  Air- 
ball  Pessary 337 

CHAPTER  XXV. 

lateriflexion,  lateral  displacement  and  alternating  ante-  and 
retroflexion  of  the  uterus. 

Lateriflexion  of  the  Uterus. — Treatment. 

Alternating  Ante-  and  Retroflf,.\io.n. — Nature  of  these  Cases^ 
Condition  of  the  Tissues  of  the  Uterus — Treatment,  General  and  Me- 
chanical       351 


14  CONTENTS  OF  VOL.  I. 

CHAPTER   XXVI. 

INCISION  AND  DILATATION   OF  THE   CERVICAL  CANAL  OF  THE  UTERUS. — 
STEM   PESSARIES. 

Incision  or  Division  of  the  Os  and  Cervix  Uteri. — Various  Methods 
of  performing  the  Operation — Means  for  maintaining  the  Canal  open 
afterwards — Dangers  of  the  Operation — Treatment  of  Cases  of  Imper- 
forate Os  Uteri. 

Dilatation  of  the  Canal  of  the  Uterus.— Dangers  of  the  Procedure 
— Means  of  effecting  Dilatation — Various  Kinds  of  Tents — Method  of 
Introduction — Metallic  Dilators. 

Stem  Pessaries. — Various  Kinds — Simple  Stems — Stems  with  Support- 
ing Vaginal  Framework 356 


CHAPTER  XXVII. 

association  of  pregnancy  with  flexions  of  the  uterus. 

General  Observations.  —  Frequency  of  Abortions  in  such  Cases: 
Reasons  for  this — Difficulty  of  Expansion  of  the  Uterus. 

Retroflexion  and  Retroversion  of  the  Gravid  Uterus. — i.  Flexion 
Present  before  Pregnancy  occurs — Natural  History,  Symptoms,  and 
Effects;  2.  Flexion  occurring  after  Pregnancy  has  commenced — Diag- 
nosis—  Treatment  —  Reduction  by  Positional  Treatment;  by  other 
Means — Trea  ment  of  the  Bladder. 

Anteflexion  of  the  Gravid  Uterus. — A  Frequent  Condition  and  a 
Frequent  Cause  of  Abortion — i.  Cases  where  the  Anteflexion  occurs 
after  Pregnancy  lias  begun — 2.  Anteflexion  precedes  the  Pregnancy — 
History  of  these  various  Cases — Reasons  why  the  Complication  is  not 
generally  recognized  as  an  Important  One — Diagnosis — Severe  Sick- 
ness a  Common  Symptom — Author's  Views  on  this  Subject — Retention 
of  Portions  of  Ovum  another  Result  of  the  Flexion — Treatment  in  va- 
rious Cases  according  to  Severity  of  the  Case — Elevation  of  the  Uterus, 
how  to  be  effected — Relief  of  the  Sickness — Modus  operaudi  of  the 
Treatment — Ur.  Copeman's  Method — Dilatation  of  the  Cervix  for  Cure 
of  Sickness  disci'ssed  and  explained. 

Subsequent  Treatment 371 

CHAPTER  XXVIII. 

THE  vomiting   OF   PREGNANCY. 

Author's  Explanation,  and  Paper  on  Subject  in  1871. 

Severe  or  Dangerous  Vomiting  in  Pregnancy.— Historical  and 
Critical  Inquiry  into  the  Subject,  with  Summary  of  Observations  re- 
corded by  Others — Account  of  Cases  published — Dr.  Copeman's  Cases: 
Explanation  of  these — Cases  observed  by  the  Author — Aubert's  Obser- 
vations on  Influence  of  Movements  of  Uterus  in  producing  Sickness — 
General  Rhtint^  o{  the  Subject. 

Treatment  of  the  Vomiting  of  Pregnancy 391 


CONTENTS  OF  VOL.  I.  1 5 

CHAPTER  XXIX. 

DISEASES   A.ND    INJURIES   OK   THE   OS   AND   CERVI.X    UTERI. 

The  "  Ulceration"  Theory  of  Uterine  Disease — Laceration  of  the  Cervix 
Uteri  :  Its  Effects  and  Results — Dr.  Etnmct's  Views  on  the  Subject — 
His  .Method  of  Treatment — Importance  of  Evcrsion  of  the  Cervical 
Lming:  Causes  of  the  same — Hypertrophy,  Cystic  Degeneration  of  the 
Os  Uteri,  etc. 

Ulcerations  of  the  Os  Uteri — Erosions — True  Ulcerations — Syphilitic  Ul- 
cerations      415 

CHAPTER   XXX. 

CHRONIC    INVERSION   OF   THE    UTERUS. 

Chronic  Inversion  of  the  Uterus. — Causes,  Effects,  and  Varieties. 
Diagnosis. 

Treatment. — Reduction  by  Systematic  and  Continuous  Pressure  aided 
by  Anxsthcsia — Treatment  by  E.\cision 426 

CHAPTER  XXXI. 
prolapsus  of  the  uterus. 

Genfrai,  Rkmakks  on  the  Pathi>Io;;y  of  the  Subject — Mechanism  by 
wliiih  the  Uterus  is  kept  in  its  Place — The  various  Conditions  present 
in  Cases  of  I'rolapsus — Illii-  •  ■  -  of  various  Conditions  and  Com- 
plications— .Mechanism  of  ^  —  Relation  to  Cystoceic,  Recto- 
cele,  and  Flexions — Hypci:  .  >ngation  of  the  Cervix  and  its 
V.iricties — S>mptoins  and  Progress  of  Prolapsus. 

Diagnosis. 

Treat.ment. — Must  be  adapted  to  the  Peculiarities  of  the  Case — Ticat- 
ment  of  Prolapsus  from  Hypertrophy  of  the  Cervix — Excision  of  the 
Part — Other  Forms  of  Prol.ipsus — .Measures  directed  (1)  to  the  Condi- 
tion of  the  Uterus;  (2)  To  the  Condition  of  the  Uterine  Supports — 
Artificial  .Means  for  maint.iining  the  Uterus  in  its  Proper  Place  in  the 
Pelvis,  by  Pessaries,  by  External  Appliances,  by  Constriction  of  the 
Vaginal  Aperture,  or  the  Canal  itself — Dcscrip<.ion  of  various  Operative 
Procedures 43O 


LIST  OF  ILLUSTRATIONS  IX  VOL.  L 


rlG-  FACE 

I.     Changes  in  Muscular  Fibres  of  Uterus 40 

The  Ovarv,  with  Pampiniform  Plexus  of  Vessels  (Savage).. . .  44 

Mucous  .Nicmbrane  of  L'tcrus  durinvj  Menstruation 49 

Uterus  during  Menstruation.  1  he  Ovary  exhibits  a  recently- 
ruptured  Graafian  Follicle 50 

A  Graafian  Follicle  preparing  for  Rupture  (A.  Farre) 51 

Section  of  (Jvary  ami  Follicle  in  Fig.  5 51 

Virgin  <>s  Uteri  (A.  Farre) 64 

Section  of  Pelvis  and  Uterus  showing  position  of  Uterus  (Life 

size) 65 

Os  Uteri  at  Eight  Months  of  Gestation  (A.  Farrr) 67 

Sectional  View  of  Os  Uteri  at  Eight  Months  of  Gestation  (A. 

Farre) 71 

E.xamination  of  Uterus  by  Means  of  Sound 73 

Lateral  Sectional  View  of  Uterus  (.A.  Farre) 76 

Retrolie.\ion  of  a  somewhat  enlarged  Uterus 77 

Bivalve  Speculum,  in  silu S4 

E.xamination  of  Uterus  by  Sims's  Speculum.     Os  Uteri  drawn 

down  by  small  hook 86 

Bivalve  Spoi  uhmi  (Cusco's  modified  by  Weiss) 87 

View  (magnified)  of  Interior  of  Cervix  Uteri  (Tyler  Smith). ...  89 

Lateral  Sectional  View  of  Uterus  (A.  Farre) Ill 

Transverse  Section  of  Uterus  at  Internal  Os  (.\.  Farre) 112 

Anteflexion  of  Uterus  with  Congestion 113 

Kctrotlexion  of  the  Uterus  accompanied  with  Congestion 114 

.Vnlcllexion  of  Uterus  with  Congestion,  in  a  Case  of  Severe 

Chronic  \'omiting 117 

Chronic   Congestive    Hypertrophy    with    Anteflexion   of   the 

Uterus ii3 

General  Hypertrophy  of  Uterus  and  Cervix  125 

Longitudinal  Hypertrophy  of  Uterus  (A.  Farre) 126 

Hypertrophy  of  Posterior  Lip  of  Os  Uteri 127 

Defective  Formation  of  Uterus  (Rokitansky) 156 

Uterus  Unicornis  (Pole) 158 

Double  Uterus  (Kussmaul) 159 

Uterus  Bilof  ularis  (Kussmaul) 160 

Normal  Position  of  Uterus,  Life  size  (see  also  Fig.  8) 165 

Position    of    Uterus    when    Bladder    is    Empty  (according  to 

Schultze) 171 

Normal  Range  of  Movement  of  Uterus  forward  or  backward  172 

Lateral  Sectional  View  of  Uterus  (A.  Farre) 190 


l8  LIST   OF  ILLUSTRATIONS   IN  VOL.    I. 

35.  Anteflexion  of  Uterus  with  Congestion I9T 

36.  Acute,  long-standing  Retroflexion  of  Uterus 193 

37.  First  Degree  of  Retroflexion  of  Uterus 205 

33.     Third  Degree  of  Retroflexion  of  Uterus 205 

39.  Section  of  Pelvis.  Life  size,  showing  Severe  Reiroflexior.  vvith 

Congestion  of  Uterus,  Patient  in  a  Vertical  Position 207 

40.  Same  as  Fig   39.     Patient  being  in  the  Prone  Position 2o3 

41.  Severe  Retroflexion  of  Uterus 212 

42.  Third  Stage  of  Anteflexion   with   Distention   of  Cavity  and 

Thickness  of  Walls  (Chronic  Menorrhagia,  etc.).     Patient 

in  Vertical  Position 215 

43.  Same  as  Fig.  42,  but  Patient  is  supposed  to  be  in  Dorsal  Posi- 

tion   217 

44.  Outlme  of  Patient  in  Genu-pectoral  Position 230 

45.  Genu-pectoral  Position  showing  Uterus  Retroverted 230 

46.  Genu-pectoral  Position.     Position  of  Uterus  changed  by  the 

Attitude  of  Patient 230 

47.  Speculum  or  Air  Tube  (Campbell's)  to  Facilitate  Change  of 

Position  of  Uterus  in  Genu-pectoral  Position 231 

48.  Graily  Hewitt's  Uterine  Dilator 233 

49.  Portion  of  Blades  of  Graily  Plewiit's  Dilator  (actual  size) 233 

50.  Tampons  in  Vaginal  Canal  (Thomas) 23S 

51.  First  Degree  of  Retroflexion  of  Uterus 24^* 

52.  Second  Degree  of  Retroflexion  of  Uterus 2-i3 

53.  Third  Degree  of  Retroflexion  of  Uterus 249 

54.  Second  Degree  of  Retroflexion,  with  Second  Degree  of  Pos- 

terior Rotation  of  Uterus  shown  on  Section  of  Pelvis  (Life 

size) 250 

55.  Third  Degree  of  Retroflexion  and  Third  Degree  of  Posterior 

Rotation  (Life  size) 252 

56.  Three  Degrees  of  Retroflexion  of  Uterus 25  3 

57.  Medium-sized   Pessary    as   Employed    by  Author  for   Retro- 

flexion. Ground  Plan  and  Sectional  View  (actual  size) 26 « 

58.  Various  Sizes  of  Rings  from  which  Pessaries  can  be  m^de. . . .  264. 

59.  Section  of  Pelvis  showing  action  of  the  Retroflexion  Pessary 

(Life  size) 26^; 

60.  Oblique  View  of  a  Medium  Hodsje  Pessary  (A.  Smith  type).. .  260 

61.  Five  Sizes  of  the  Retroflexion  Pessary 267 

62.  Three  larger  Sizes  of  the  Retroflexion  Pessary 26S 

63.  Gehrung's  Retroflexion  Pessary 273 

64.  Greenhalgh's  Padded  Retroflexion  Pessary 274 

65.  Thomas's  .Modification  of  Cutter's  Retroflexion  Pessary 275 

66.  (Author's)  Combined  Stem  and  Hodge  Pessary  for  Treatment 

of  Retroflexion 270 

67.  Retroverted  Uterus,  with  Simpson's  Sound  introduced 2S2 

68.  Retroverted  Uterus,  with  a  jointed  Sound  introduced 2S3 

69.  Marked  Anteflexion  (a  Museum  Preparation) 287 

70.  Acute  Anteflexion  and  Congestion  of  Uterus 288 

71.  Normal  Range  of  Movements  of  Uterus,  in  forward  or  back- 

ward Direction 293 

72.  Position  of  Uterus  according  to  Schultze,  when  the  Bladder  is 

Empty 294 

73.  First  Degree  of  Anteflexion  of  Uterus 299 

74.  Second  Degree  of  Anteflexion 300 


LIST  OF  ILLUSTRATIONS   IN  VOL.   I.  1 9 

75.  Third  Degree  of  Anteflexion 300 

76.  Complete  Anteversion  of  Uterus 301 

77.  Three  DcRrees  of  Anteflexion  of  Uterus 302 

78.  Severe  Anteflexion  (Emmcl) 303 

79.  Anteflexion  with  Posterior  Rotation  of  the  Uterus;  Section  of 

Pelvis 304 

80.  Outline  of  Uterus,  Anteflexion  with  Posterior  Rotation 305 

81.  Anteflexion  of  Uterus  (Life  size).  First  Degree,  shown  on  Sec- 

lion  of  Pelvis 306 

82.  Second  Degree  ol  Anteflexion  (Life  size),  Section  of  Pelvis..  307 

83.  Severe  Chronic  Anteflexion,  showing  much  Hypertrophy. . . .  309 

84.  Anteflexion  of  Uterus  and  Congestion.  (Case  of  severe  Chronic 

Vomting) 311 

85.  Large  Anicflexed  Uterus 313 

86.  Chronic  Anteflexion.     Pouched  Condition  of  Uterus 31S 

87.  Author's  Cradle  Pessary,  tn  situ 327 

88.  Cradle   Pessary  (large  size),  shown  in  Position,  Uterus,  etc. 

(Life  size) 323 

89.  Triangles  indicating  Proper  Relation  of  Sides  of  Cradle  Pes- 

sary    333 

90.  Large  size  Bar  Cradle  Pessary 339 

91.  Large  size  Crutch  Cradle  Pessary 339 

92.  Outline  of  Cradle  Pessary  and  Uterus  (Life  size),  to  show  Ac- 

tion of  Pessary 340 

93.  Large  size  Crutch  Cradle,  seen  from  above 341 

94.  Profile  View  of  three  sizes  of  Cradle  Pessary 341 

95.  Medium  size  Crutch  Cradle  Pessary 342 

96.  Full  size  Crutch  Cradle  Pessary 342 

97.  Extra  thick  No.  3  size  Spring  Cradle  Pessary 343 

98.  Another  View  of  Pessary  shown  in  Fig.  97 343 

99.  Large  size  Spring  Cradle  Pessary  in  Action 344 

100.     A  Special  .Mode  of  using  Cradle  Pessary 345 

loi.     Gehrung's  Anteflexion  Pessaries 347 

102  and  103.     Thomas's  Anteflexion  Pessaries 34S 

104.     Mundii's  Modification  of  Thomas's  Pessary 349 

105  and  106.     Pessary  for  Treatment  of  alternate  Ante-  and  Retro- 
flexion    355 

107  and  108.     Barnes's  Tent  Introducer 3C2 

109  and  no.     Graily  Hewitt's  Uterine  Dilator 364 

111.  Priestley's  Dilator 365 

112.  Marion-Sims's  Dilator 365 

113.  Chambers's  Stem,  and  Introducer 366 

1 14.  Granville  Bantock's  Stem,  and  Introducer 366 

115.  Godson's  Stem   368 

116.  Lawson  Tait's  Stem 368 

117.  Graily  Hewitt's  Stem  Pessary  (so  called  "  Padlock"  Pessary).  369 

118.  Wynn  Williams's  Stem  Pessary 370 

119.  Gravid  Uterus,  in  a  State  of  Retroflexion 378 

120.  Anteflexion  of  Gravid  Uterus  at  about  Fourth  Month 385 

121.  Retained  Ovum,  or  Clots,  with  Anteflexion  of  Uterus 387 

122.  Double  Lateral  Laceration  of  Cervix  Uteri  (Emmet) 417 

123.  Watch-spring  Tourniquet   for  Operation    of    Restoration   of 

Torn  Cervix  (Emmet) 419 


20  LIST   OF  ILLUSTRATIONS   IX  VOL.   I. 

124.  Shape  of   Raw  Surfaces  after  Denudation.      Operation  for 

Restoration  of  Torn  Cervix  (Emmet) 420 

125.  Tenaculum  Forceps  for  Operation  of  Restoration  of  Tom 

Cervix 421 

126.  White's  Method  of  Replacing  Inversion  of  Uterus 433 

127.  Aveling's  Instrument  for  Replacing  Inverted  Uterus 434 

128.  Inversion  of  Uterus  and  large  Polypoidal  Tumor 435 

129.  Section  of  Pelvis,  showing  Relation  of  Uterus,  Vagina,  Peri- 

neum, etc.     (Life  size) 438 

130.  Complete  Prolapsus  with  Retroflexion  of  Uterus 441 

131.  Anteflexion  of  Uterus  with  Cysiocele 443 

f  32.     Chronic  Retroflexion  with  Rectocele 444 

133.  Supra-vaginal   Hypertrophy,  with  Prolapsus  of  the  Uterus. .  445 

134.  Hypertrophic  Elongation  of  Infra-vaginal   Cervix  Uteri  with 

Prolapsus 446 

135.  Another  Case  similar  to  that  shown  in  Fig.  134 447 

136.  Hypertrophic  Elongation  of  Cervix  with  Retroflexion 448 

137.  Prolapsus  of  Bladder  with  Prolapsus  of  Hypertrophied  Cervix 

(A.  Farre) 451 

138.  Ecraseur  with  Annealed  Steel  Wire,  for  Amputation  of  Cervix 

Uteri 455 

139  and  140.     Operation  for  Restoration  of  Perineum 463 

141.  Author's  Method  of  Constricting  Vagina,   in  Operation  for 

Restoration  of  Perineum 466 

142.  Marion-Sims's  Operation  for  Constricting  Vagina 467 

143.  144,  and  145,  show  Emmet's   Plan   for   Restoring  the   Rectal 

Sphincter  in  Cases  of  Laceration  of   Perineum 468 


THE 

Pathology,  Diagnosis,  and  Treatment 


OF  THE 


DISEASES   OF   WOMEN. 


CHAPTKR   I. 


General  Considerations  respecting  the  Diseases  of  the 
Sexual  Organs  in  Women. 

Relations  subsisting  between  General  and  Local  Diseases. — Im- 
portance of  Maintenance  of  proper  Nutritional  Power  as  afTicting  tlie 
General  Condition  of  the  Patient  —  Nutritional  Weakness  of  the  Uterus 
a  Cause  of  Softness  of  the  Uterus,  and  an  Important  Factor  in  causing 
other  Diseases  of  the  Organ — Relative  Importance  of  Afifcctions  of  the 
Uterus  and  the  Ovaries. 

The  performance  of  the  functions  of  various  organs  of 
the  body  in  a  normal  manner  inij)Iics  a  general  condition 
of  health  of  all  the  organs,  and  disorder  of  one  of  them 
has  generally  a  disturbing  effect  upon  others.  Thus  symp- 
toms whicli  at  first  sight  appear  to  indicate  local  disease  or 
disorder  may,  on  more  complete  investigation,  prove  to 
be  the  manifestation  of  some  more  general  disturbance. 
Hence  a  sound  view  of  a  particular  case  must  of  necessity 
be  a  broad  view:  there  is  room  for  reproach  to  anything 
like  an  exclusive  view.  Exclusiveness  may  be  on  either 
side.  There  can  be  no  question  that  it  is  as  much  a  mis- 
take to  regard  the  "local  "  as  the  "general"  element  in  the 
case  exclusively;  and  while  the  importance  of  the  "  local  " 
element  may  have  been  sometimes  over-estimated  in  the 
practice  of  gynecologists,  the  fact  remains  that  the  "gen- 
eral "  has  also  very  much  too  frequently  usurped  the  pro^ei 
place  of  the  other  in  the  practice  of  those  who  are  not 
gynaecologists.  The  practitioner  who  refuses  to  look  at  the 
two  sides  dispassionately  will  possibly  make  great  mistakes. 


34  DISEASES   OF   WOMEN. 

He  is  certain,  at  all  events,  to  lose  many  opportunities  of 
doing  good  and  relieving  suffering. 

In  the  study  of  the  diseases  of  the  female  sexual  organs 
we  meet  with  many  and  complex  problems,  and  much  un- 
certainty and  diversity  of  opinion  still  prevail  in  regard  to 
the  decision  of  many  of  these  problems.  It  is  quite  evi- 
dent that  no  decisive  advance  can  be  made  in  the  settling 
of  disputed  points  unless  the  primary  one  of  the  connection 
between  "general"  and  "local''  disease  be  more  satisfac- 
torily determined.  It  may  be  confidently  expected  that 
some  of  the  more  important  of  existing  differences  of 
opinion  will  be  found  reconcilable  by  full  consideration  of 
the  facts  adducible  in  reference  to  the  manner  in  which 
"general"  disease  is  capable  of  influencing  or  predisposing 
to  or  actually  producing  "local"  diseases  of  the  female 
sexual  organs.  It  is  the  more  likely  that  this  satisfactory 
result  will  be  attained,  inasmuch  as  the  explanations  to  be 
given  involve  concessions  to  both  parties  and  give  distinct 
credit  to  each  of  them.  It  may  be  said  that  it  is  no  new 
thing  to  point  out  the  importance  of  the  "  general  "  element 
in  dealing  with  gynaecological  cases.  Many  previous 
writers  have  dealt  with  it,  some  prominently  so.  But  there 
are  various  important  considerations  in  connection  with 
this  subject  which  it  is  my  object  to  develop  more  particu- 
larly in  the  following  pages,  and  for  which  some  degree  of 
novelty  may  be  claimed.  I  refer  to  the  subject  of  a  de- 
ficient and  defective  nutrition  of  the  body  generally  and  its 
effects  on  the  sexual  organs,  more  particularly  the  uterus, 
in  predisposing  to  or  in  the  production  of  actual  disease. 
There  appear  to  be  good  grounds  for  believing  that,  ex- 
cluding accidents  and  injuries,  the  primary  defect,  the  first 
step  in  the  downward  course,  leading  finally  to  established 
local  disease,  is  a  general  weakening  or  impairment  of  the 
nutritional  activity  of  the  body  generally.  There  is,  first, 
a  general  weakness  influencing  more  or  less  the  whole  of 
the  organs  of  tlie  body  in  an  injurious  sense;  there  is,  in 
the  second  place,  a  particular  and  local  weakness  evidencing 
itself  in  the  local  disease  and  particular  local  symptoms. 
The  clinical  facts  which  are  adducible  in  favor  of  this  gen- 
eralization are  before  us,  and  its  correctness  may  be  attested 
without  difficulty  by  simple  observation  of  facts  daily  pass- 
ing under  our  eyes. 

It  may  be  urged  that  the  statement  in  the  foregoing  para- 
graph is  a  truism.     It  is  so.     But  it  is  nevertheless  a  truth 


DISEASES   OF  THE   SEXUAL   ORGAN'S   IX  WOMEN.     35 

wliich  has  yet  to  be  applied  to  the  explanation  of  various 
difficulties  encountered  by  p;ynoecological  pathologists. 

In  the  year  1S67  I  adopted  as  the  subject  for  an  inaugural 
address  at  University  College,  "  Nutrition  the  Basis  of  the 
Treatment  of  Disease."*  I  mention  this  as  showing  that 
my  attention  had  been  some  time  ago  attracted  to  the  im- 
[lortance  of  "general  "  views.  But  it  was  not  until  the  last 
live  or  six  years  that  the  more  advanced  and  complete  gen- 
t'lalization  as  to  the  influence  of  general  imjierfect  nutrition 
in  producing  disease  of  the  female  sexual  organs  forced 
itself  on  my  notice.  I  had  been  for  a  long  time  unable  to 
account  satisfactorily  for  the  fact  that  in  cases  coming 
under  my  notice  the  uterus  was  so  often  found  in  a  soft, 
flaccid  stale.  Observation  of  very  numerous  cases  and 
careful  inquiry  into  the  antecedents  of  these  cases  gave  so 
uniform  a  history  of  long-standing  mal-nutrititm — a  general 
kind  of  semi-starvation,  in  fact — that  I  gradually  acquired 
the  conviction  that  there  was  a  real  connection  between  them, 
and  that  the  relation  was  actually  one  of  cause  and  effect. 

In  the  last  (third)  edition  of  this  work  the  very  great  fre- 
quency with  which  patients  suffering  from  uterine  symp- 
toms were  found  to  present  vari(ius  forms  and  degrees  of 
flexion  of  the  uterus  was  pointed  out,  and  the  opinion  ex- 
pressed that  these  sufferings  are  traceable  to  the  altered 
shape  and  position  of  the  uterus.  But  it  was  also  insisted 
upon  that  "  the  change  in  the  form  and  shape  of  the  uterus 
is  frequently  brought  about  in  consequence  of  the  tissues 
of  the  uterus  being  previously  in  a  state  of  unusual  soft- 
ness." f 

The  nature  antl  cause  of  this  unusual  softness  of  the 
uterus  have,  since  the  publication  of  the  last  edition  of  this 
work,  much  occupied  my  attention.  This  unusual  softness, 
which  had  formerly  much  puzzled  me  to  account  for,  I  have 
since  seen  reason  to  trace  to  a  previous  geaeral  weakness 
and  want  of  nutrition  of  the  uterus.  It  is  met  with  in 
those  individuals,  for  the  most  part,  who  had  been  imper- 
fectly and  inadequately  nourished  for  some  time  previously. 
Instead,  therefore,  of  attributing  this  unusual  softness  to 
chronic  inflammation,  which  was   the  best  explanation  of 


*  In  1879  I  delivered  an  address  to  the  Harveian  Society  on  "Chronic 
Starvation"  (see  Lancet,  Jan.,  1879),  in  which  the  same  subject  v;as 
further  developed. 

t  3d  ed.  1872,  p.  2. 


36  DISEASES   OF  WOMEN. 

the  matter  I  could  offer  in  the  )'ear  1872,  I  now  wish  to  sub- 
stitute for  it  the  explanation  just  given. 

The  foregoing  remarks  are  anticipatory  in  a  sense.  And 
they  apply  for  the  most  part  to  the  uterus,  which  is  only 
one  of  the  female  sexual  organs;  but  they  will  indicate  the 
view  entertained  by  the  writer  as  to  the  importance  of  the 
"general"  and  its  relations  to  the  "local  "  element  in  dis- 
cussing the  subject  of  diseases  of  the  female  sexual  organs. 

A  further  question  is  to  be  considered.  The  female  sexual 
organs  consist  principally  of  two  organs — the  uterus  and 
the  ovaries.  What  is  the  comparative  preponderance  of 
these  organs  in  the  origination  of  disease,  and  what  is  the 
comparative  importance  of  diseases  of  the  one  or  other  of 
them? 

Some  gynaecologists  attribute  the  greater  degree  of  im- 
portance to  the  uterus,  while  others  consider  diseases  of 
the  ovar}'  the  more  important.  The  difference  of  opinion 
is  attributable,  for  the  most  part,  to  the  different  interpreta- 
tion of  symptoms  by  advocates  of  opposing  views.  Thus, 
pain  located  laterally  in  the  pelvis  is  considered  to  indicate 
ovarian  irritation  or  inflammation  by  some  authorities, 
whereas  a  different  explanation  would  be  given  by  opposing 
pathologists. 

It  is  necessary  to  weigh  well  the  clinical  and  other  facts 
adducible  in  favor  of  the  uterine  or  ovarian  origin  of  ob- 
served symptoms.  The  ovaries  are  undoubtedly  most  im- 
portant organs  in  the  female  economy,  and  have  indeed  a 
great  influence,  in  an  indirect  manner,  on  diseases  of  the 
uterus.  In  one  sense  of  the  word  the  ovaries  may  be  said 
indeed  to  be  more  important  than  the  uterus.  Yet  the  ma- 
jority of  clinical  observers  are  of  opinion  that  uterine  dis- 
orders numerically  preponderate  over  the  disorders  of  the 
ovaries.  The  ovaries  are  liable  to  one  form  of  disease — 
cystic  degeneration — which  is  a  malady  of  very  great  im- 
portance; while  the  uterus  is  liable  to  alterations  and  dis- 
orders, many  of  v.hich  involve  continuous  suffering  and 
give  rise  to  severe  or  troublesome  symptoms.  On  the 
whole,  it  appears  that  symptoms  are  far  more  frequently 
traceable  to  the  uterus  than  to  the  ovary  as  the  offending 
organ.  The  inflammatory  conditions  of  the  peritoneum 
covering  the  ovaries  or  parts  immediately  adjacent  are  con- 
sidered by  some  pathologists  as  having  special  importance, 
"pelvic  peritonitis'"  being  supposed  to  be  a  condition  fre- 
quently present,  and  capable  of  giving  rise  to  many  of  the 


HISTORY   OF  THE   UTERUS  AND   OVARIES.  37 

symptoms  which  are  more  ordinarily  set  down  to  the  uterus. 
Tliese  do  not,  however,  appear  to  be  good  grounds  for  re- 
i^arding  this  condition  as  a  common  one.  Of  late  years 
tlie  introduction  of  Batiey's  operation  has  been  tlie  means 
of  acquainting  us  with  the  fact  that  the  ovaries  are,  at  all 
events,  occasionally  affected  with  contractions,  degeneration 
of  tissue,  and  other  important  changes.  It  seems  certain 
that  the  list  of  ovarian  diseases  is  undergoing  an  increase. 


CHAPTER   II. 

NATfRAL  History  of  the  Uterus  and  Ovaries. 

Nati'rai.  History  ok  the  Utervs. — Effects  of  Mcnslruaiion — Preg- 
nancy— Sexual  Intercourse. 

Ovariks:  Phknomkna  ok  MK.NSTRfATloN  AND  Ovi'i.ATio.N. — Vasculaf 
and  Erectile  .Apparatus  of  Female  Sexual  Organs:  Hulb  of  the  Vagina: 
Bulb  of  the  Ovary — Mechanism  of  Ovulation — Rouget's  Researrlies — 
Menstruation — Recent  Researches  by  Kiindrat,  Enijclmann,  Williams, 
and  LeopoM  as  to  the  Nature  of  Menstruation — Source  of  the  Hlood — 
Phenomena  observed — Age,  Periodicity,  Duration,  Quantity,  and  Qual- 
ity of  the  Discharge. 

NATURAL    HISTORY    OF    THE    UTERUS. 

The  Uterus  is  an  organ  wliich  has  an  extremely  important 
position  in  the  female  economy,  and  the  changes  and  modi- 
fications witnessed  in  its  shape,  si/e,  and  te.xture,  in  its  vas- 
cular condition,  and  in  its  relations  to  the  nervous  centres, 
exercise  a  profound  influence  on  the  individual  who  is  the 
subject  of  them.  They  produce  discomfort  of  various  kinds, 
they  interfere  with  the  natural  performance  of  important 
functions,  prevent  procreation,  and  involve  many  other 
minor  inconveniences;  not  infrequently  they  predispose  to 
the  occurrence  of  other  disorders  capable  of  shortening  life 
or  bringing  it  to  a  sudden  and  abrupt  conclusion. 

Life  in  the  woman  is  made  up  of  three  periods:  i.  The 
period  preceding  that  of  sexual  activity;  2.  The  period  of 
sexual  activity;  3.  The  period  following  the  cessation  of 
sexual  activity.  The  peculiarities  appertaining  to  these 
three  several  periods  appear  to  be  almost  wholly  dependent 
on,  and  subordinate  to,  the  condition  of  the  sexual  organs 
at  the  several  periods  in  question.  The  sexual  organs  con- 
sist essentially  of  the  uterus  and  the  ovaries,  the  due  exer- 


38  DISEASES   OF  WOMEN. 

cise  of  the  sexual  functions  being  dependent  on  the  presence 
of  these  two  organs  in  their  integrit)'.  In  the  exercise  of 
the  sexual  functions  the  ovary  is  the  more  essential  organ 
of  the  two:  physiological  reasoning  conclusively  indicates 
this.  It  may  be  that  alterations  in  the  ovaries,  impercepti- 
ble perhaps  to  us  as  observers,  influence  the  economy  at 
large  in  a  profound  manner;  but  wliat  we  know  at  present 
ratlier  justifies  the  belief  that,  in  cases  where  the  disorder 
is  dependent  on  the  sexual  organs,  the  uterus  is  the  particu- 
lar organ  most  frequently  at  fault. 

Before  puberty  has  arrived,  the  uterus  is  small  and  un- 
developed, and  has,  functionally,  no  existence.  And  it  is 
remarkable  that,  during  this  period,  and  whilst  it  remains 
in  its  dormant  condition,  it  is  not  liable  to  disease.  Dis- 
ease of  the  organ  only  begins  to  sliow  itself  when  it  begins 
functionally  to  live.  After  the  climacteric  age  has  been 
passed,  and  uterine  life  has  ceased,  we  find  that  the  condi- 
tion of  the  uterus  is  one  very  closely  analogous  with  that 
which  subsists  before  the  arrival  of  puberty.  The  uterus 
becomes  atrophied — physiologically  dead — and  the  liability 
to  disease  for  the  most  part  ceases.  Thus,  during  the  first 
and  the  third  stages  of  the  woman's  life,  equally,  the  uterus 
is  an  organ  lying  inactive  and  almost  powerless  in  the 
economy.  But  this  is  not  all.  The  uterus  not  only  enjoys 
a  life  of  its  own,  so  to  speak,  but  it  has  a  life  or  a  succession 
of  lives  within  this.  If  the  woman  becomes  impregnated, 
the  uterus,  previously  developed  and  matured,  forthwith 
starts  on  a  new  road  of  development,  and  after  the  term  of 
gestation  has  been  completed,  relapses  into  its  previous 
condition.  The  building  up  of  the  gravid  uterus  is  not 
more  wonderful  than  its  subsequent  destruction.  Succes- 
sive pregnancies  involve  each  the  formation  and  destruction 
of  the  organ;  for  each  pregnancy  there  is  the  life  and  death 
of  an  entire  uterus. 

The  uterus  has  thus  a  life  of  its  own,  distir.ct  from,  and 
in  a  certain  degree  disconnected  with,  that  of  other  organs 
of  the  body.  And  from  all  these  considerations  it  results 
that  the  diseases  of  the  uterus  have  also  peculiarities  sep- 
arating them  from  diseases  of  other  organs. 

In  diseases  of  all  organs  of  the  body,  wherever  situate, 
we  witness  for  the  most  part  onl)^  alterations  of  natural 
processes;  and  the  diseases  observed  in  the  uterus,  in  like 
manner,  bear  upon  them  the  impress  of  their  locality.  It 
is  not   intended   to  imply  that   pathological  processes  and 


HISTORY   OF  THE   UTERUS  AXD   OVARIES.  39 

conditions,  such  as  are  met  with  in  other  organs  of  the 
body,  may  not  be  met  with  in  the  uterus.  Such  may  un- 
questionably be  the  case:  cancer,  for  instance,  attacks  the 
pylorus  and  the  uterus,  and  the  disease  is  in  both  positions 
integrally  the  same,  although  the  tissues  among  which  it 
makes  its  inroads  are  not  of  the  same  kind  in  the  two  cases. 
But  it  will  be  conceded,  that  the  interpretation  of  the 
pathological  and  other  changes  in  the  uterus  would  be  diffi- 
cult by  one  unacquainted  with  the  peculiarities  of  its  struc- 
ture and  with  the  nature  of  the  functions  which  it  is  called 
upon  to  perform  in  the  economy.  And  it  results  from  what 
has  been  now  said  that  the  peculiar  structure  and  physio, 
logical  functions  of  the  uterus  impress  upon  it  pathological 
conditions  and  characteristics,  with  which  we  have  nothing 
tlioroughly  identical,  and  sometimes  not  even  analogous,  in 
the  pathological  conditions  of  other  organs  of  the  body. 

There  are  two  great  functions  in  which  the  uterus  is 
prominently  concerned,  and  which  are  most  powerful  dis- 
turbing influences  in  rc^gard  to  its  textural  condition;  these 
are,  menstruation  and  gestation.  There  is  a  third  in  which 
it  is  also  concerned,  viz.,  se.xtial  congress,  which  is  also  capa- 
l)le,  though  probably  in  a  less  degree,  of  affecting  its  tex- 
tural condition.  How,  and  why,  the  exercise  of  these 
functions  respectively  affects  the  physical  condition  of  the 
organ,  and  leads  to  disease,  must  now  be  pointed  out. 

Menstru.^tio.v. — During  the  whole  of  sexual  life,  the 
uterus  is  each  month  the  seat  of  an  unusual  congestion  of 
all  its  blood-vessels.  Its  circulation  is  more  active,  it  en- 
larges, the  sinuses — which  are  to  be  seen  on  making  a  sec- 
tion of  the  uterine  walls  as  cavities  of  considerable  size — 
become  filled  with  blood,  and  its  tissues  engorged  and  ex- 
panded. It  will  be  presently  shown  (see  "Phenomena  of 
Menstruation")  how  profusely  the  organ  is  supplied  with 
blood-vessels;  it  is  further  to  be  remarked  that  the  veins 
are  unprovided  with  valves,  tlje  result  of  which  is  that  con- 
gestion of  the  uterir\e  plexuses  readily  occurs.  The  men- 
strual congestion  of  the  uterus  lasts  for  some  days  even  in 
health,  the  duration  being  probably  from  first  to  last  not 
less  than  a  week,  and  where  the  period  is  prolonged  it  may 
be  considerably  over  a  week.  Scanzoni  estimates  the  ordi- 
nar)'  duration  of  menstrual  congestion  indeed  as  nearly 
half  of  the  whole  four  weeks  which  usually  constitute  the 
"period."  Prolongation  of  the  menstrual  period,  or  un- 
usual intensity  of  the  congestion  for  a  shorter  time,  will 


40 


DISEASES  OF  WOMEN. 


Fig.  I.* 


thus  lead  in  the  end  to  a  chronic  condition  of  engorgement; 
for  if  the  heart  be  weak,  or  if  other  circumstances  interfere 
with  the  quick  removal  of  the  excessive  quantit)'  of  blood 
from  the  organ,  the  vessels  do  not  recover  their  proper  size, 
they  remain  permanentl)^  larger  than  they  should  be,  and 

as  a  consequence  the  uterus  itself 
acquires  a  size  which  is  excessive 
and  unnatural. 

Thus,  under  ordinary  circum- 
stances the  menstrual  process 
tends  to  produce  uterine  conges- 
tion and  enlargement,  but  when 
menstruation  is  disturbed,  this 
congestion  is  intensified  and  per- 
petuated. Scanzoni — whose  classi- 
cal treatise  on  chronic  metritisf  ap- 
peared almost  simultaneously  with 
the  first  edition  of  this  work — con- 
siders sudden  suppression  of  men- 
struation as  one  of  the  most  impor- 
tant causesof  chronic  inflammation 
of  the  uterus;  for  the  engorgement 
of  the  uterus  natural  to  menstrua- 
tion becomes,  when  unrelieved,  a 
true  congestion,  the  blood  stagnat- 
ing in  the  widely-open  vessels,  and 
thus  leading  to  other  important 
textural  changes.  The  severe  and 
troublesome  headache  not  uncom- 
monly observed  at  the  outset  of 
the  menstrual  period,  where  there 
is  a  temporar}'  obstruction  to  the 
escape  of  the  blood  from  the 
uterus,  indicates  probably  the  transference  of  this  conges- 
tion from  the  uterus  to  the  head. 

Pregnancy. — The  changes  in  the  uterus  which  are  the 
result  of  gestation  are  of  a  very  important  character. 

The  most  remarkable  change  is  the  increase  of  the  .y/s^  of 
the  organ  which   is   observed;    for  after  the  foetus  has  been 

*  Fig.  I  represents  three  conditions  of  the  uterine  muscular  fibres:  A. 
Fibres  from  the  uterus  in  the  non-gravid  state;  B.  Fibres  from  the  fully 
developed  gravid  uterus;  and  C.  Fibres  undergoing  fatty  degeneration 
after  parturition. 

f  "  Die  Chronische  Metritis,"  4to.     Berlin,  1S63. 


HISTORY   OF   THE    UTERUS   AND   OVARIES.  4I 

expelled  and  the  uterus  has  been  thoroughly  emptied  of 
its  contents,  its  bulk  greatly  exceeds  tiiat  of  the  unim- 
pregnated  uterus.  Under  favorable  circumstances,  as  is 
well  known,  the  size  of  the  uterus  rapidly  diminishes  dur- 
ing the  few  weeks  following  parturition,  until  it  finally 
hecomes  nearly,  but  not  quite,  as  small  as  before  the  pro- 
cess of  gestation  commenced.  This  diminution  in  the  size 
of  the  uterus  is  the  result  of  a  peculiar  process,  by  which 
the  very  large  muscular  fibres,  whose  contractile  power  has 
l)cen  exercised  in  expelling  the  uterine  contents,  become 
first  affected  with  fatty  dcgi-neration,  and  then  undergo  ab- 
sorption and  completely  disapj">ear.  The  vessels  of  the 
uterus  also  lieconie  at  the  same  time  much  reduced  in  size. 
The  process  by  virtue  of  wliich  the  uterus  returns  to  its 
normal  condition  is  now  known  as  the  process  of  involution. 
The  time  occupied  in  involution  is  probaljly  about  two 
months,  the  greatest  diminution  in  size  occurring  during 
Uie  second  week,  after  which  time,  under  ordinary  circum- 
stances, the  enormous  muscular  fibres  characteristic  of  the 
pregnant  uterus  have  become  disintegrated.  Immediately 
after  delivery  the  uterus  has  a  thickness  of  one  inch  and  a 
length  of  about  eight  inches;  but  by  the  end  of  the  first 
month  the  reduction  in  size  is  nearly  completely  accom- 
plished. The  muscular  librcs  begin  to  undergo  transforma- 
tion into  fatty  molecules  about  four  days  after  labor,  and 
while  the  metamorphosis  is  proceeding  the  uterus  is  friable 
and  soft.  The  new  tissue  of  the  uterus  begins  to  be  evi- 
dent at  the  end  of  four  weeks  after  parturition,  and  shortly 
after  this  we  may  conclude  that  the  uterus  ought  to  be  re- 
constructed.* During  a  month  and  upward  after  parturi- 
tion, the  uterus  is  consequently  unduly  large  and  vascular, 
and  it  very  frequently  happens  that  circumstances  interfere 
with  the  efficient  and  timely  completion  of  its  involution. 
If  the  placenta  be  not  e.xpelled  rapidly,  and  the  uterus  re- 
main unduly  enlarged  for  a  time,  this  circumstance  gives  rise 
to  subsequent  difliculties,  for  coagula  form  in  the  sinuses 
of  the  uterus,  and  even  after  expulsion  of  the  placenta 
these  coagula  by  their  bulk  interfere  with  the  due  contrac- 
tion of  the  organ.  Again,  if  the  expulsion  of  these  coagula 
be  deferred,  as  is  not  very  uncommon,  the  return  of  the 

*See  Heschl's  valuable  researches  on  this  subject,  "Zeits.  der  Gesells. 
der  Acrzie."  Wien.  1852.  Also  Dr.  Farre.  "Cycl.  An.  and  Pliys.,"and 
Dr.  Priestley  "  On  the  Development  of  the  Gravid  Uterus."    Lond.  i860. 


42  DISEASES   OF   WOMEN. 

uterus  to  its  normal  size  is  proportionately  interfered  with. 
Again,  when  the  nutritive  changes  of  the  body  generally 
are  in  a  low  state,  and  when  the  individual  is  debilitated 
from  any  cause,  the  normal  metamorphosis  of  the  uterine 
tissue  is'  disturbed,  the  blood  circulates  less  rapidh',  the 
effete  material  is  not  removed,  and  the  organ  continues 
large,  unwieldy,  and  congested.  Defective  involution  of 
the  uterus  may  thus  be  a  consequence  of  various  disturbing 
causes  in  operation  after  cliildbirth,  all  of  wliich  tend  to 
leave  it  larger  than  it  should  be.  The  new  uterus,  con- 
structed by  growth  of  new  material,  and  built  up  in  the 
existing  large  framework,  is  also  too  large  and  its  blood- 
vessels too  full,  and  this  creates  a  very  strong  predisposi- 
tion to  the  perpetuation  of  an  abnormal  nutrition-process. 
This  increased  size  leads  to  mechanical  changes  in  its  posi- 
tion and  shape.  It  is  almost  unnecessary  to  mention  how 
very  important,  in  postponing  the  normal  involution  pro- 
cess, must  be  the  occurrence  of  puerperal  fever,  uterine 
phlebitis,  etc.  Abortions  are  both  an  effect  and  a  cause  of 
defective  involution  of  the  uterus;  but  quickly  repeated 
pregnancy  undoubtedly  tends  to  produce  it,  and  thus  to 
predispose  to  chronic  inflammation;  the  reason  being  that 
before  the  uterus  is  thoroughly  renovated,  it  is  called  upon 
again  to  undergo  the  gestation  process.  Quickly  recur- 
ring pregnancies,  especially  when  they  occasionally  result 
in  abortions,  both  cause  and  are  caused  by  a  defective  invo- 
lution process. 

Sexual  Intercourse. — The  erection  of  the  uterus  de- 
scribed by  Rouget  and  others  as  occurring  during  ovulation 
(see  "  Phenomena  of  Menstruation")  occurs  also  during  the 
act  of  intercourse.  At  least  this  is  highly  probable.  Sex- 
ual excesses  predispose  to  chronic  congestion  of  the  uterus, 
inasmuch  as  they  involve  too  frequently  repeated,  or  too 
long  continued,  engorgement  of  it.  In  young  women  re- 
cently married  it  is  by  no  means  uncommon  to  meet  with 
a  condition  plainly  brought  about  by  excess  of  the  kind 
here  alluded  to,  and  but  little  is  required  under  such  cir- 
cumstances to  produce  a  chronic  engorgement  of  the  organ, 
and  the  further  train  of  evils  usually  following  in  its  wake. 
It  appears  to  be  quite  certain,  also,  that  unnatural  excita- 
tion of  the  generative  organs  in  women  leads  to  uterine 
mischief  of  various  kinds,  and  promotes  and  maintains  a 
chronic  congestion  of  the  organ  and  of  its  vessels,  tending 
to  give  rise  to  various  secondary  disorders, 


HISTORY    OF   THE    UTERUS   AND   OVARIES.  43 

This  brief  retrospect  of  the  mechanical  results  of  ilie 
performance  of  the  natural  functions  of  the  uterus  will  suf- 
fice to  show  the  direction  in  which  we  are  to  look  for  the 
explanation  of  its  various  morbid  conditions.  The  nutri- 
tion-process in  the  uterus  is,  as  a  consequence,  very  liable 
to  derangement,  this  derangement  resulting  in  the  produc- 
tion of  important  alterations  in  the  size,  consistence,  and 
structural  condition  of  the  organ. 

ovaries:    natural    history. —  phenomena    of    menstrua- 
tion   AND    ovulation. 

The  importance  of  the  physiology  of  menstruation  and 
ovulation  in  ihe  study  of  the  morbid  processes  witnessed 
in  the  female  generative  organs  is  obvious. 

All  the  generative  organs  are  well  supplied  with  blood. 
When  in  a  state  of  rest  they  contain  but  a  moderate  supply 
of  blood,  but  untlcr  excitement  this  is  very  largely  increased. 
This  increase  is  effected  by  the  distension  of  certain  struc- 
tures— erectile  organs — which  are  at  other  times  compara- 
tively empty. 

The  orifice  of  the  vagina  has  on  each  side  of  it  an  elon- 
gated leech-sliapcd  body,  the  bulb  of  the  vai^ina,  composed 
of  a  large  numljcr  of  tortuous  veins,  closely  packed  together 
in  a  fibrous  investment,  prolonged  upwards  in  the  middle 
line  to  the  glans  clitoridis.  This  is  a  provision  for  erection, 
the  blood  being  detained  in  the  veins  by  the  action  of  suit- 
able muscles.  Further,  the  vaginal  canal  is  surrounded 
with  a  belt  of  blood-vessels,  forming  a  large  plexus  of  veins. 
The  arrangement  of  the  vessels  supplying  the  uterus  is  of 
considerable  importance,  and  Rouget*  has  particularly  in- 
vestigated this  subject  in  a  memoir  of  great  value.  The 
utero-ovarian  artery,  which  supplies  the  uterus  with  blood, 
passes  upward.  Its  first  branches,  to  the  cervix,  are  small; 
but  opposite  the  body  of  the  uierus  it  gives  off  suddenly 
twelve  to  eighteen  short  trunks,  which  pursue  at  once  a 
spiral  direction  and  divide  into  a  large  number  of  smaller 
branches.  When  injected,  these  vessels  are  seen  to  lie  so 
close  as  to  quite  cover  the  sides  of  the  uterus.  The  body 
of  the  uterus  thus  receives  a  very  profuse  arterial  supply, 
and  the  spiral  convolutions  of  the  branches  may  be  seen 
projecting  into  the  sinuses  of  the  uterine  structure.     The 

*  "  Recherches  sur  les  Organes  6rectilcs  de  la  Fcmme."  Brown- 
S6quard's  "Journ.  de  Physiol."  torn,  i. 


44 


DISEASES   OF   WOMEN. 


veins  in  which  these  arteries  terminate  are  still  more  nu- 
merous and  capacious,  and  they  form  a  plexus  covering  the 
sides  of  the  body  of  the  uterus.  Below,  these  veins  end 
in  the  pudendal  veins,  in  the  middle  they  end  in  the  uterine 
veins,  and  above  in  the  spermatic  veins.  It  results  that  the 
sides  of  the  uterus  are  covered  with  a  layer  of  considerable 
thickness,  composed  of  blood-vessels  having  great  capacity, 
and  it  is  further  to  be  recollected  that  the  tissue  of  the 
uterus  itself  contains  large  sinuses — receptacles  for  venous 
blood. 

The  ovaries  are  supplied  with  blood  from  the  utero-ova- 
rian  artery  and  from  the  spermatic.  The  arterial  trunk 
passes  along  near  the  base  of  the  ovarj'',  and  in  its  passage 
gives  off  a  series  of  ten  or  twelve  branches;  these  branches 
divide  at  once,  assume  a  convoluted  arrangement,  and 
finally  enter  the  ovary.  The  veins  coming  from  the  ovary 
form  a  special  bulb,  the  bulb  of  the  ovary,  composed  like  the 

vaginal  bulb  of  a  series 
^^^-  ^-  of  tortuous  veins,  sus- 

ceptible of  consider- 
able distension.  The 
bulb  of  the  ovary  has 
an  elongated  form,  its 
length  a  little  exceed- 
ing tliat  of  the  ovary, 
it  is  somewhat  flatten- 

..^r-^K-^^^i^^^^^^^^^  ed,  not  quite  half  an 
^J-^^ti^.^i^ypf^^^Sy':-^  inch  thick,  and  a  little 

deeper  than  this;  alto- 
gether its  size  is  not 
much  inferior  to  that  of  the  vaginal  bulb.  The  pampini- 
form plexus  of  veins,  a  further  portion  of  the  vascular  ap- 
paratus here  met  with,  lies  below  the  ovarian  bulb  in  the 
folds  of  the  broad  ligament.  The  bulb  of  the  ovary  is  a 
structure  only  recently  known.  The  first  allusion  to  it 
seems  to  be  in  a  paper  communicated  by  Mr.  Traer  to  the 
Anatomical  Society  of  Paris.  It  is  well  depicted  in  Dr. 
Savage's  beautifully  illustrated  work,*  and  in  Rouget's 
memoir  {loc.  cii.)  it  is  made  the  subject  of  an  elaborate  in- 
vestigation conjointly  with  those  of  the  other  erectile 
structures  of  the  female  generative  organs  (see  Fig.  2). 


*  "  Illustraiions  of  the  Surgery  of  the  Female  Generative  Organs,' 
London,  Churchill,  1863. 


HISTORY   OF  THE   UTERUS   AND   OVARIES.  45 

In  the  memoir  of  Rouget  it  is  shown  that  the  function 
of  ovulation  is  probably  greatly  dependent  for  its  efficient 
performance  on  the  presence  of  muscular  structures  not 
before  described  in  the  human  subject.  Erecliliiy  is  de- 
pendent, as  Rouget  remarks,  on  association  of  structures 
for  reception  of  a  large  quantity  of  blood,  and  for  deten- 
tion of  that  blood.  The  bulb  of  the  vagina  is  an  erectile 
structure;  the  muscular  apparatus  connected  with  this  is 
well  known.  And  with  reference  to  the  bulb  of  the  ovary, 
Rouget  endeavors  to  show  that  there  is  a  muscular  appara- 
tus for  the  control  of  its  vascular  supply,  and  for  constitut- 
ing it  an  erectile  organ.  In  lower  animals  the  ovary  is 
brought  into  coaptation  with  the  oviduct  by  a  mechanism 
which  is  not  quite  the  same,  though  on  the  same  general 
plan,  in  different  species.  Thus  in  birds,  where  we  find  the 
muscular  apparatus  connected  with  the  ovaries  very  well 
marked,  the  oviduct  is  surrounded  by  a  muscular  structure 
or  envelope  within  which  the  coils  of  the  ovitluct  lie.  The 
contractile  fibres  are  so  placed  that  a  twofold  effect  follows 
from  their  contraction,  viz.,  the  infundibulum  is  opened  out, 
and  at  the  same  time  appro.ximated  to  the  ovary  in  order 
to  receive  the  ova.  The  muscles  producing  this  effect  are 
of  the  involuntary  kind,  and  radiate  after  the  manner  of  a 
fan  in  the  folds  of  the  membrane  enclosing  the  oviduct. 

Rouget,  after  introducing  other  anatomical  facts  in  ref- 
erence to  the  comparative  anatomy  of  the  subject,  goes  on 
to  state  that  in  the  human  female  there  are  to  be  found 
muscular  fibres  arranged  on  an  analogous  plan;  that  they 
form  a  system  covering  the  uterus,  ovaries,  and  appendages; 
and  that  the  muscular  fibres  belonging  to  this  system  pass 
from  the  lumbar  region  to  the  ovary  and  to  the  fimbriae 
near  it,  while  others  pass  from  the  uterus  over  the  ovary, 
and  onward  to  the  fimbriae  of  the  Fallopian  tube  also,  and 
that  the  simultaneous  contraction  of  these  two  sets  of  fibres 
has  necessarily  the  effect  of  bringing  the  fimbriae  near  the 
ovary.  The  mechanism  of  the  process  is,  he  contends,  iden- 
tical in  the  case  of  the  human  subject  and  in  animals  lower 
in  the  scale. 

Thus  then,  the  muscular  fibres  described,  together  with 
the  vascular  apparatus  of  the  uterus  and  ovary,  constitute 
together,  if  we  follow  Rouget,  the  erectile  structure  of  the 
internal  generative  organs.  Ovulation  is  accompanied  by 
the  following  phenomena:  the  Graafian  follicles  being  ma- 
ture, or  nearly  so,  the  muscular  fibres  above  described  are 


46  DISEASES   OF  WOMEN. 

set  in  action  and  the  fimbriae  of  the  tube  are  thus  made  to 
grasp  the  ovary,  at  the  same  time  that  they  induce  and 
maintain  a  condition  of  erection  of  the  ovarian  bulb.  This 
spasmodic  erection  is  present  so  long  as  the  ovary  and  the 
Fallopian  tube  remain  in  contact,  and  when  the  rupture  of 
the  Graafian  follicle  happens,  the  ovum  passes  into  the 
proper  channel.  Ordinarily  the  ovipont  occurs,  because  of 
the  presence  of  ripe  ova  in  ilie  ovary;  and  with  this  process 
it  has  been  almost  generally  admitted  the  phenomena  of 
menstruation  are  associated,  although  of  late  years  this  view 
of  the  matter  has  been  strongly  opposed.  It  is  probable 
that  the  act  of  congress  often  determines  an  ovipont,  whicli 
without  it  would  be  postponed  for  a  time.  Here  the  act  of 
intercourse  induces  erection  of  the  external  generative  or- 
gans, and  doubtless  also  that  erection  of  the  internal  organs 
above  alluded  to,  the  result  being  escape  of  an  ovule. 
Rouget  contended  that  the  uterus  is  equally  with  the  ovary 
an  erectile  organ,  that  its  erection  occurs  simultaneously 
with  that  of  the  ovary,  and  that  the  final  result  of  this  erec- 
tion, during  which  the  uterus  is  kept  gorged  with  blood,  is 
exudation  of  that  sanguineous  fluid  from  the  surface  of  its 
lining  membrane,  forming  the  menstrual  discharge.  This 
view  of  the  cause  of  the  haemorrhage  has  been  of  late  seri- 
ously impugned. 

The  action  of  the  muscular  apparatus  in  bringing  the 
ovary  to  the  open  end  of  the  Fallopian  tube  is  probably 
greatly  assisted  by  the  engorgement  of  the  ovary  and  of  its 
bulb,  for  when  the  pelvic  vessels  are  injected  artificially 
after  death,  the  effect  is  to  bring  the  ovary  close  to  the 
open  mouth  of  the  Fallopian  tube;  and  it  has  indeed  been 
assumed  by  some  that  the  injection  of  the  ovarian  bulb  is  a 
principal  agent  in  effecting  the  adjustment  necessary  for 
the  ovipont. 

We  thus  see,  in  the  vascular  and  muscular  structures  of 
the  internal  generative  organs,  provision  made  for  the  sup- 
ply of  vast  quantities  of  blood  to  these  organs.  In  the  hu- 
man female  the  engorgement  and  full  distension  of  the 
vessels  occur  periodically,  the  period  of  engorgement  being 
that  of  menstruation;  while  it  would  appear  that  it  is  liable 
— during  sexual  life  at  least — to  occur  also  during  inter- 
course. We  may  in  the  ner.t  place  consider  briefly  certain 
of  the  other  phenomena  of  menstruation. 

The  process  known  under  the  names  "menstruation,"  the 
"catamenial   discharge,"  etc.,   is  one  in  the  production  of 


HISTORY    OF   THE    UTERUS   AND    OVARIES.  4/ 

which  two  organs  are  concerned — the  uterus  and  the  ovary. 
Menstruation  is  usually  an  indication  of  the  fact  that  the 
ovaries  are  in  activity — in  other  words,  that  ova  are  being 
formed,  developed,  and  maturated  in  the  ovaries.  That 
menstruatiun  may  occur  in  cases  where  the  ovaries  have 
been  removed,  appears  possible  from  certain  observations 
made  in  the  last  few  years.  By  "  menstruation"  is  meant  a 
periodical  discharge  of  a  sanguineous  fluid  from  the  uterus, 
iliis  discharge  being  attended,  as  already  remarked,  with 
an  engorged  or  congested  state  of  the  uterus,  ovaries,  and 
adjacent  organs,  in  most  cases  by  hyperaesthesia  of  the 
parts  in  question,  and  by  disturbances,  of  various  kinds  and 
degrees,  of  other  functions  of  the  body.  It  is,  in  a  certaia 
sense,  analogous  to  the  icstrus  in  the  lower  animals,  the 
presence  of  menstruation  being  an  indication  that  the 
woman  is  capable  of  being  impregnated;  but  the  woman 
differs  from  these  animals  in  this  respect,  that  she  is  capable 
of  being  impregnateil,  not  at  the  time  during  which  the 
discharge  itself  occurs  only,  but  also  during  the  intervals 
between  the  periodic  discharges.  Very  important  additions 
have  been  made  to  our  knowledge  of  the  physiology  of 
menstruation  during  the  last  ten  years.  The  minute  anat- 
omy of  the  lining  of  the  uterus  at  different  periods  had  been 
studied  carefully  by  Kundrat  and  Engelmann,  by  John 
Williams,  Leopold,  and  others,  and  various  important  facts 
have  come  to  light. 

An  essential  element  in  the  question  of  the  changes  oc- 
curring in  the  uterine  mucous  membrane  during  menstrua- 
tion is  the  nature  of  the  membrane  itself,  and  its  relation 
to  the  uterine  wall.  Dr.  John  Williams*  points  out  that 
the  uterus  should  be  regarded  as  a  mucous  membrane, 
whose  libre-cells  have  undergone  great  development.  He 
considers  that  three  fourths  of  the  thickness  of  the  walls 
of  the  uterus  is  really  "  mucosa,"  the  tubules  of  this  mu- 
cosa extending  more  deeply  into  the  wall  than  is  gen- 
erally supposed.  He  considers,  therefore,  that  the  terms 
muscular  wall  and  mucous  membrane  as  generally  applied 
are  misnomers.  This  view  of  the  matter,  supported  by  ar- 
guments derived  from  the  analogy  of  the  structure  of  the 
stomach,  and  of  uteri  of  other  animals,  is  original,  and  has 
important  bearings  on  the  vexed  question  as  to  the  changes 
in  the  uterine  mucous  lining  during  menstruation.     Kun- 

*  "  Obstet.  Trans.,"  vol.  xvj.  p.  20^. 


^8  DISEASES   OF  WOMEN. 

drat  and  Engelmann  in  1873  published  their  researches  on 
the  changes  in  the  uterus  during  the  catamenia.  The)' con- 
sidered that  the  uterus  is  active  not  onh-  during  the  men- 
strual flow,  but  both  before  and  after,  and  that  the  menstrual 
activity  is,  in  other  words,  spread  over  a  much  longer  time 
than  that  represented  by  the  actual  menstrual  flow.  They 
were  of  opinion  that  the  haemorrhage  of  menstruation  is  due 
to  fatty  degeneration  of  the  mucous  membrane,  the  occur- 
rence of  which  degenerative  change  they  substantiated  by 
their  observations. 

Dr.  John  Williams  in  1S74*  brought  before  the  Royal 
Society  of  London  the  results  of  observation  of  the  uteri  of 
nine  women  who  had  died  in  different  stages  of  the  men- 
strual period — his  conclusions  being  that  menstruation  con- 
sists in  rapid  growth  and  deca}'  of  the  mucous  membrane; 
the  discharge  consists  of  the  debris  of  the  mucous  mem- 
brane; the  bleeding  is  from  the  vessels  of  the  body  of  the 
uterus;  that,  the  mucous  membrane  having  undergone  fatty 
degeneration,  blood  becomes  extravasated  into  its  substance; 
the  membrane  then  undergoes  rapid  disintegration  and  is 
entirely  carried  away  with  the  menstrual  discharge.  In  a 
Jater  essay  f  Dr.  Williams  has  published  results  of  further 
investigations  with  observations  of  other  cases,  and  in  a 
third  paper  still  further  cases,!  making  nineteen  observa- 
tions altogether. 

Barnsfather  in  1875  §  records  his  clinical  experience,  ex- 
pending over  some  time,  with  frequent  microscopic  exami- 
nations of  menstrual  secretions,  and  he  finds  exfoliations 
present  in  all  cases,  the  exfoliations  being  thicker  in  cases 
of  menstrual  difficulty. 

Leopold  II  has  given  the  results  of  his  observations  in 
several  cases,  which  are  to  the  efTect  that  the  disintegration 
of  the  mucous  membrane  is.  when  it  occurs,  very  slight,  and 
affects  only  the  great  superficial  layer  of  the  mucous  mem- 
brane; while  in  some  cases,  where  death  occurred  a  few 
days  after  the  period,  the  mucous  membrane  was  still  of 
considerable  thickness,  Leopold  did  not  find  evidence  of 
fatty  degeneration  in  his  cases. 

*  The  structure  of  the  mucous  mambrane  of  the  uterus  and  its  peri 
odical  cnanges. — Pfvc.  of  Koyal  Soc.  1S74. 
f  "  Obst.  Trans.,"  vol.  xvi.  p.  206. 
XOhsUt.  Jour.,  Dec.  1S77. 
^  Cincinnati  Med.  A'eii'S. 
I  "  Die  Uierusschleinihaut  und  die  Menstruation."    Leipzig,  1877, 


HISTORY   OF  THE    UTERUS   AND   OVARIES, 


49 


The  evidence  which  is  to  be  gathered  on  the  subject,  al- 
though by  no  means  uniformly  pointing  to  the  disintegra- 
tion and  separation  of  a  considerable  thickness  of  the 
mucous  membrane  in  normal  menstruation,  shows  the  ex- 
treme probability  of  a  destruction  and  removal  of  the  su- 
perficial layer  in  all  cases.  It  is  perfectly  certain  that  the 
mucous  membrane,  at  or  about  the  menstrual  period,  is  a 
]iulpy,  thick,  exceedingly  vascular  substance.  The  haemor- 
rhage occurs  either  from  the  open  mouths  of  the  tubules, 
cither  with  accompanying  disintegration  of  the  superficial 
layer,  or  without  it.  That  fatty  degeneration  does  occur  is 
undoubted,  though  it  seems  open  to  question  if  this  is  uni- 
versally the  case.  It  does  not  appear  that  the  whole  thick- 
ness of  the  mucous  membrane  is  ever  removed;  and,  indeed, 

Fig.  3. 


'i    A 


this  is  hardly  possible  if  we  accept  Dr.  Williams's  view  that 
the  mucosa,  in  a  physiological  sense,  includes  much  of  the 
muscular  wall  of  the  uterus.  It  is  probable  that  further 
inquiries  will  reconcile  the  present  apparent  discrepancies 
between  the  results  of  late  observers;  some  of  ihcm  are, 
indeed,  explainable  by  want  of  accurate  information  as  to 
the  precise  date  of  the  last  menstruation. 

Some  years  ago  I  had  opportunities  on  four  or  five  oc- 
casions of  examining  the  uterus  during  menstruation.  In 
the  case  of  a  woman  who  died  while  menstruating,  after  an 
operation  for  hernia,  I  saw  the  uterus  lined  by  a  deeply  red, 
velvety  soft  structure,  on  the  free  surface  of  which  were  to 
be  seen  the  open  mouths  of  the  uterine  glands  (see  Fig.  3). 


50 


blSEA§ES   OF   \VOME!C. 


Fig.  4  represents  the  condition  observed  in  a  3'oung  woman 
who  died,  while  menstruating,  from  the  effects  of  a  burn, 
in  University  College  Hospital.  In  other  cases  I  have  found 
the  mucous  membrane  in  actual  process  of  disintegration. 
The  changes  in  the  ovary  coincident  with  menstruation 
may  next  be  alluded  to.  Supposing  matters  take  their 
ordinary  course,  the  ovary  produces  on  its  surface,  and 
periodically,  matured  Graafian  follicles,  one  or  more  at  a 
time,  causing  the  ovary  to  present  an  elevation  the  size  of  a 
nut-kernel,  and  constituted  by  the  follicle  distended  with 
blood  and  containing  the  ovule.  This  condition  of  the  fol- 
licle is  certainl}'^  frequently  present  at  the  time  menstrua- 

FlG.  4. 


^\\|'^.     '^' 


tion  occurs,  but  it  is  probable  that  such  a  matured  condi- 
tion may  be  present  at  other  times  also.  The  next  event  is 
tlie  rupture  of  this  follicle  and  passage  of  its  contents  into 
the  Fallopian  tube — the  ovipont — provided  for  in  the  man- 
ner already  described.  Fig.  5  (from  Dr.  Farre)  shows  a 
Graafian  follicle  preparing  for  rupture;  Fig.  6  a  section  of 
the  same  follicle,  exhibiting  its  cavity  and  a  blood-clot  with- 
in. Rupture  of  one  or  more  follicles  probably  occurs  at, 
or  before,  or  shortl)'^  after,  each  menstruation,  though  not 
limited  absolutely  to  that  period.  After  the  follicles  have 
discharged  their  contents,  the  cavity  of  the  follicle  and  the 
interior  of  the  Fallopian  tube  may  or  may  not  remain  in  con- 


HISTORY    OF  THE    UTERUS  AND   OVARIES. 


51 


nection  with  each  other:  if  further  bleeding  from  the  inte- 
rior of  tlie  follicle  occur?,  the  blood  will  or  will  not  find  iis 
way  into  the  uterus,  according  to  circumstances.  It  is  ob- 
vious that  the  continuous  application  of  the  Fallopian  tubes 
to  the  ovary  is  expedient  during  the  whole  time  follicles  are 

Fig.  5. 


liable  to  become  ruptured,  or  there  might  be  escape  of  the 
follicular  contents  into  the  peritoneal  cavity.  Such  escape 
and  consequent  failure  of  the  ovipont  is  not  very  uncom- 
mon, leading  to  sterility,  to  e.xtra-utorine  foetaiion,  to  effu- 
sion of  blood  into  the  peritoneal  cavity,  and  other  disorders. 

Fig.  6. 


The  Graafian  follicle,  having  nischarged  its  contents,  the 
blood  within  it  ordinarily  coagulates,  the  cavity  shrinks  up, 
and  by  the  successive  growth  of  follicles  lying  deeper  in  the 
ovarian  stroma,  the  used-up  follicle  sinks  back  toward  the 
middle  of  the  ovary,  becomes  smaller  and  smaller,  and  dis- 


$2  DISEASES   OF  WOMEN. 

appears  at  the  end  of  three  or  four  months.  The  retrogreS-* 
sion  of  the  follicle  is  marked  also  by  changes  of  color  due 
chiefly  to  the  transformation  the  blood-clot  undergoes,  and 
to  the  changes  in  the  very  vascular  lining  of  the  follicle. 
After  bursting,  the  follicle  is  known  as  2^  false  corpus  luteum. 

From  observations  made  in  several  subjects  Dr.  John 
Williams  believes  that  ova  are  usually  discharged  from  the 
ovary  before  the  appearance  of  the  monthly  flow  with 
which  it  is  connected.*  In  ten  out  of  fourteen,  rupture  of 
a  follicle  or  haemorrhage  into  its  cavity  had  occurred  before 
the  return  of  the  catamenia;  in  one  it  was  doubtful  whether 
rupture  of  a  follicle  or  the  appearance  of  the  discharge 
would  have  occurred  first;  in  two  a  menstrual  period  had 
passed  without  maturation  of  a  follicle,  and  in  one  a  peri- 
odical discharge  was  imminent,  though  the  ovaries  con- 
tained no  mature  Graafian  follicle. 

Leopold's  observations  tend  also  to  show  that  the  Graaf- 
ian follicle  bursts  before  the  menstrual  period,  rather  than 
after  it.  On  the  other  hand,  observations  are  not  wanting 
to  show  that  the  ovipont  in  some  cases  occurs  after  the  com- 
mencement of  the  menstrual  flow.  On  the  whole  it  seems 
]irobable  that  there  is  a  variation  in  regard  to  the  time  of 
the  ovipont,  though  it  more  often  than  not  occurs  near  the 
menstrual  period.  It  seems  probable,  from  the  observa- 
tions of  Coste,  that  it  is  not  uncommon!}-  determined  and 
brought  about  by  sexual  intercourse.  The  question  of 
the  ordinary  time  of  the  ovipont  is  interesting  as  bearing 
on  that  of  the  time  of  impregnation.  The  Hebrew  custom 
is  in  favor  of  the  view  taken  by  Dr.  Williams,  but  the 
known  fact  that  the  spermatozoa  may  remain  active  for 
several  days  after  intercourse  has  occurred  vitiates  conclu- 
sions drawn  from  actual  experience  as  to  the  efficiency  of 
single  acts  of  intercourse  at  particular  periods. 

The  commencement  of  the  process  of  menstruation  is  usu- 
ally preceded  b}'  certain  changes  in  the  outward  confor- 
mation and  appearance.  The  general  signs  of  the  arrival 
of  pviberty  in  the  woman  are  thus  eloquently  enumerated 
by  Brierre  de  Boismont:  "  Puberty  at  last  arrives.  An  im- 
mense revolution  takes  place  in  the  system  of  the  young 
girl.  To  her  slim  lank  form  succeeds  plumpness  and  c^race. 
Her  step,  uncertain  and  languid,  becomes  firm  and  spirited. 

*  On  the  discharge  of  ova  and  its  relation  in  point  of  time  to  Menstru- 
ation.— Proc.  of  Roy.  Sec.  1875. 


ttlSTOkV   or   TltE    UtEUCS  AND   OVAntES.  53 

The  soft  glance  of  the  eye  reveals  the  fire  of  the  soul. 
Changes  not  less  remarkable  take  place  in  her  physique. 
The  chest,  narrow  and  contracted,  swells  and  expands. 
The  lungs  breathe  more  fully.  The  heart  throws  with 
greater  force  the  blood  to  the  extremities.  The  celUilo- 
adipose  tissue  develops  the  admirable  contour  which  con- 
stitutes the  beauty  of  woman.  Of  all  the  organs  that 
feel  the  influence  of  puberty,  the  uterus  and  its  annexes  are 
those  in  which  it  is  most  evident. 

"  Tiie  uterus,  ovaries.  Fallopian  tubes  and  breasts  increase 
immensely.  The  bones  and  muscles  partake  of  this  gen- 
eral development.  Even  the  moial  offers  differences  not 
less  marked.  The  young  girl,  truly  an  infant  in  her  tastes, 
inclinations  and  desires,  experiences  all  at  once  a  complete 
metamorphosis.  Restless  and  dreamy,  she  does  not  com- 
prehend the  new  sentiments  that  agitate  her.  All  the 
senses  are  quickened;  a  soft  glow  pervades  her  whole 
nature.  An  unusual  fulness  is  felt  in  the  pelvic  organs,  the 
most  important  phenomenon  of  puberty,  that  which  trans- 
forms the  girl  into  the  woman,  now  manifests  itscTf  by  the 
catamenial  flow  which  heralds  the  fitness  for  maternity."* 

There  are  also  sometimes  present  in  young  women  who 
are  about  to  menstruate  certain  sensations,  more  or  less 
marked  in  different  cases,  and  most  intense  in  those  cases 
where  the  appearance  of  the  menstrual  discharge  is  a  little 
delayed.  These  symptoms  are  known  by  the  term  molimiua 
menstniationis.  The  chief  symptoms  of  the  menstrual  moli- 
men — the  attempt  at  menstruation,  the  evidence  of  ovarian 
activity — are  as  follows:  A  sensation  of  weight  and  fulness 
in  the  pelvis  and  its  neighborhood,  together  with  a  "  bearing 
down"  or  dragging  sensation;  pains  radiating  from  the 
loins  downward  toward  the  perinieum,  and  occasionally 
extending  down  the  thighs;  tenderness  over  the  hypogastric 
and  inguinal  regions;  a  feeling  of  heat  in  these  regions  so 
intense  as  to  be  described  "as  burning"  by  some  patients, 
irritability  of  the  bladder,  frequency  of  micturition,  and 
inability  to  evacuate  the  bladder,  are  more  rarely  observed. 
The  digestive  system  sympathizing,  there  are  diarrhoea,  or 
constipation,  nausea,  inappetency.  Fretfulness,  or  change 
of  temper  and  disposition,  may  also  be  noticed;  in  fact, 
many  of  those  symptoms  usually  classed  under  the  denomi- 

*  "  De  la  Menstruation  dans  ses  rapports  physiologiques  et  patholo- 
giqucs,  8vo.      Paris,  1S42,  p.  i. 


54 


DISEASES   OE  WOMEN. 


nation  "  hysterica]  "  may  be  present.  Tlie  local  symptoms 
are  tlie  most  constant.  Wlien  symptoms  of  tlie  above 
character  are  observed  at  intervals  of  three  or  four  weeks, 
persisting  in  each  periodic  recurrence  for  two,  three,  or  four 
days  together,  in  a  young  woman  who  presents  outward 
signs  of  liaving  arrived  at  puberty,  they  are  evidence  of  the 
existence  of  ovarian  action,  and  constitute  the  menstrual 
molimen.  The  characteristic  point  about  these  symptoms 
is  their  periodicity. 

In  some  cases  where  menstruation  is  absent  there  is 
witnessed  a  periodical  haemorrhage,  or  exudation  of  blood 
from  some  other  part,  as  from  the  lungs,  stomach,  con- 
junctiva, surface  of  an  ulcer,  etc.  In  such  cases  there  is  said 
to  be  vicarious  menstruatio7i. 

The  a^e  during  which  the  catamcnial  discharge  occurs 
varies;  but,  as  a  rule,  it  begins  during  the  ages  of  14  and 
16,  and  ceases  between  the  ages  of  40  and  50.  For  about 
thirty  years  of  the  woman's  life  this  discharge  recurs  peri- 
odically. With  reference  to  the  age  at  which  it  com- 
mences, we  have  observations  by  Roberton,*  Whitehead,  f 
Brierre  de  Boismont,J  and  Szukits.§  In  358  cases  observed 
by  myself,  menstruation  occurred  for  the  first  time 


At  the 
<< 

age  of  10  in    3 
II  "  12 
"       12  "  29 
"      13  "  43 
"       14  "  73 
"      15  "  62 

cases 

At  the 

age  of 

1 8  in  23  cases 

19  "  10     " 

20  "    6     '* 

21  "    2     " 
24  "    I     " 

<< 

"      16  "  61 
"      17  "  33 

Total 

.    .    358 

Statistics  of  2,696  cases  at  University  College  Hospital 
obtained  from  women  who  applied  at  this  hospital  to  be 
attended  in  their  confinements,  and  collected  for  me  by 
Mr.  Walter  Rigden,  are  as  follows: 

Of  the  2,696  cases,  menstruation  occurred  for  the  first 
time 


*"  Observations   and   Notes    on    the    Physiology   and    Diseases   of 

Women,  and  on  Practical  Midwifery,"  8vo.      1S51. 

f  "  On  the  Causes  and  Treatment  of  Abortion  and  Sterility,"  8vo.    1847. 

X  op.  cit. 

§  See    an  abstract   of    his    observations    in    Schmidt's    "Jahrb."  bd. 
xcvii.  p.  331. 


HISTORY 

OF  THE 

Atth 

e  age  of    9 

n       3  cases 

"     10 

•'     14     •• 

"     II 

"     60     " 

"     12 

"   170     •' 

"     13 

"  353     " 

"     14 

"  560     " 

"     15 

•  540     " 

"     16 

"  455     " 

"     17 

"  272     " 

OF  THE  UTERUS  AND  OVARIES. 


5^ 


At  the  age  of 

iS  in 

150  cases 

19  " 

76     " 

20  " 

29     " 

21  " 

7     " 

22  " 

3     " 

23  " 

2     " 

24  " 

0     " 

25  " 

0     " 

26  " 

2     " 

The  mean  ago  is  1496,  about.  Tlie  greater  number  of 
these  cases  were  liospital  out-patients. 

The  mean  age  in  4,000  cases  referred  to  by  Whitehead 
was  15  years  6^  months.  In  2,169  cases  collected  by 
Roberton,  Lee,  and  Murpliy,  the  mean  age  was  14  years 
II  months.  Szukits  found  the  mean  age  to  be.  in  6C5 
women  born  in  Vienna,  15  years  Sfr  months;  and  in  1,610 
women  born  in  the  country,  16  years  rl  months,  which  re- 
sult, as  regards  the  influence  of  town  life  in  hastening  the 
first  appearance  of  the  catamenia,  agrees  with  that  arrived 
at  by  Hrierre  de  Boismont  in  Paris.  The  latter  observer 
states  that  amongst  women  belonging  to  the  upper  classes 
of  society,  the  average  age  of  commencement  was  as  early 
as  13  years  8  months.  Although  the  age  14-16  is  the  most 
common,  yet  there  are  numerous  exceptions  to  this  rule. 
In  Roberton's  450  cases,  ten  began  to  menstruate  as  early 
as  II  years  old.  and  nineteen  at  12.  The  youngest  of 
Szukits' cases  was,  in  the  town  class  11  years  and  in  the 
country  class  10  years  old.  In  three  out  of  35S  cases  noted 
by  myself,  menstruation  began  at  the  age  of  10  years,  and 
although  the  largest  number  of  my  own  cases — 73  out  of 
358 — menstruated  first  at  the  age  of  14,  a  very  considerable 
number  menstruated  first  as  late  as  the  age  of  18. 

The  mean  age  of  the  commencement  of  the  catamenia 
appears  to  be  about  two  years  earlier  in  warmer  than  in 
more  temperate  climates.  Thus  in  India  the  mean  age  in 
597  cases  collected  by  Roberton  was  13  years.  It  was 
formerly  supposed,  on  the  assertions  of  Montesquieu  and 
Ilaller,  that  Hindu  women  began  to  menstruate,  as  a  rule, 
at  8,  9,  and  10  years  of  age;  but  facts  collected  by  Rober- 
ton conclusively  show  the-  incorrectness  of  this  opinion.  It 
appears,  however,  from  Rol)erton's  tables,  that  "  the  pro- 
portion of  Hindus  who  arrive  at  puberty  at  the  ages  of  12, 
13,  and  14,"  is  far  greater  than  is  observed  in  women  living 
in  our  own  temperate  climate.  This  early  arrival  of  the 
catamenia   is  attributed  by  Roberton  to   the   influence   of 


56  DISEASES   OF  WOMEN. 

race — to  the  fact,  that  for  many  generations  (upward  of 
three  thousand  years)  it  has  been  the  custom  of  this  people 
to  give  their  daughters  in  marriage  immediately  on  the 
arrival  of  puberty.  This  custom  has,  in  Roberton's  opin- 
ion; produced  and  perpetuated  a  kind  of  "  family  peculiar- 
ity." Montesquieu  and  Haller  held  that  "climate"  is  the 
determining  cause  of  this  difference.  More  recent  statistics 
are  in  the  same  direction.  Thus  Vogt's  researches  show 
that  in  Norwa)^  the  average  first  appearance  is  the  age  of 
1 6' 1 2.  We  may  contrast  this  with  the  average  at  Univer- 
sity College  Hospital  of  14  g6.  Toulin  and  Lagneau  have 
collected  observations  on  cases  in  various  latitudes  pre- 
sented to  the  International  Medical  Congress  at  Paris  in 
1867,*  the  general  conclusions  from  which  are  in  confirma- 
tion of  the  fact  of  the  earlier  appearance  of  menstruation 
in  hot  climates.  And  it  would  appear  that  climate  is  really 
the  determining  element  in  the  difference  observed,  between 
extremely  hot  and  extremely  cold  countries,  a  difference 
represented  by  from  three  to  four  years. 

The  /afesf  age  at  which  the  catamenia  may  commence  is 
open  to  great  variations;  but,  as  a  rule,  it  is  not  postponed 
beyond  the  age  of  18.  Brierre  de  Boismont  found  that, 
out  of  352  "femmes  de  la  capitale,"  twenty  began  to  men- 
struate at  18  }'ears,  six  at  19,  five  at  20,  two  at  21,  four  at 
22,  and  two  at  the  age  of  23.  The  latest  age  given  by 
Roberton  is  also  23.  Szukits  gives  the  age  of  22  as  the 
latest  at  which  the  first  appearance  occurred  in  the  Vienna 
class;  but  of  those  from  the  country  one  woman  began  to 
menstruate  as  late  as  25.  The  latest  age  in  my  own  series 
was  24.  In  a  case  quoted  by  Meissner,  the  catamenia  first 
appeared  at  the  age  of  42. f 

The  cessation  of  menstruation  occurs  in  the  majority  of 
cases  between  the  ages  of  40  and  50.  The  number  of  cases 
in  which  the  cessation  takes  place  before  40  is  greater  than 
the  number  of  those  in  which  the  final  appearance  of  the 
catamenia  occurs  after  the  age  of  50.  (Brierre  de  Bois- 
mont.) There  appears,  however,  to  be  a  great  diversitv  in 
the  results  obtained  by  various  observers  on  this  point. 
Thus,  in  the  cases,  181  in  number,  of  the  author  just  quoted 
the  age  at  which  the  final  cessation  most  frequently  (18  out 
of   181)  occurred,  was  40;  while  in  Roberton's  cases  it  was 

*  New  S\'d.  Soc,  "  Bien.  Retrosp."  for  1S67-8,  p.  377. 
f  Meissner,  "  Frauenzimmerkrankheiten,"  ii.  741. 


HISTURV    OF   THE    UTERUS   AND    OVARIES. 


57 


most  frequently  observed  (in  26  out  of  77  cases)  at  the  age 
of  50;  in  tlie  majority  of  the  cases  observed  by  Szukits  at 
46-50.  The  earliest  period  at  which  the  cessation  may  take 
place  is  shown  by  the  following  recorded  facts:  Of  Brierre 
de  Boismont's  181  cases,  the  cessation  was  noticed  in  seven 
before  the  age  of  30,  the  earliest  being  at  the  age  of  21. 
The  earliest  cessation  in  Roberton's  77  cases  was  at  the 
age  of  35.     Szukits  gives  two  cases  at  the  age  of  30. 

The   following  table  shows   the  results  of  my  observa- 
tions in  55  cases: 

Menstruation  ceased  at 
the  age  of  30  in  i  case 


33  ' 

•   I 

34  * 

'   2 

35  ' 

'    I 

37  ' 

'    I 

33- 

3 

39  * 

'   I 

40  • 

'  2 

41  ' 

'  2 

43  ' 

'  3 

44  ■ 

•      '> 

45  ' 

•  6 

Menstruation    ceased     at 
the  ape  of  46  in  2  cases 
"     ••         47  "  4     •• 
"     ••         43  "   5     •■ 
"     "         49  "  4     "and  1  still  men- 

•' 

" 

50  "  4 
5J  •'  3 
53  "  »     ' 

sirualing  at 
that  age 

'and  I  still  men- 

— 

struating  at 
that  age 

Total 


55 


Perhaps  the  most  interesting  class  of  facts  in  connection 
with  this  subject  has  reference  to  the  latest  age  at  which 
menstruation  may  occur.  There  is  very  little  doubt  that 
some  of  the  cases  related  as  cases  of  late  menstruation  are 
not  cases  of  menstruation  proper  at  all;  but  it  must  be 
allowed  that  occasionally  a  discharge,  sanguineous  and 
periodic,  may  be  present  at  a  very  late  age.  Gardicn  re- 
lates the  case  of  a  woman  said  to  have  been  perfectly  regu- 
lar at  the  age  of  75.  Up  to  the  age  of  55  there  are  a 
sufficiently  large  number  of  cases;  but  after  that  age  true 
menstruation  is  exceedingly  rare.  Brierre  de  Boismont 
gives  five  after  the  age  of  55,  out  of  181,  one  being  as  late 
as  60.  Roberton  (<y>.  (//.  p.  185)  gives  four  out  of  79  as 
occurring  after  55,  two  of  which  were  at  the  age  of  60,  and 
one  as  late  as  70.  Lastly,  Szukits  gives  one  case  (his  latest) 
at  the  age  of  60. 

Some,  apparently  well  authenticated,  cases  of  menstrua- 
tion at  very  advanced  ages,  viz.,  at  91,  So,  87,  59,  and  70 
years  of  age,  are  related  in  the  work  of  the  late  Dr.  D.  D. 
Davis.* 


"  Principles  and  Practice  of  Obstetric  Medicine,"  vol.  i.  p.  239. 


Menstruation  ceased  at  65  in  i  case 
'•  "        72  "  I     " 

Total     .     .      q 


58  DISEASES   OF   WOMEN. 

In  reference  to  the  foregoing  statements,  it  is  probable 
that  many  of  the  apparent  exceptions  to  general  rules 
quoted  were  cases  in  which  pathological  elements  were 
more  or  less  intermixed. 

Menstruation  ceases  earlier  in  India;  but  everywhere  the 
duration  in  years  is  much  the  same.  For  about  thirty 
years  menstruation  continues.  Roberton  is  of  opinion  that 
early  cessation  is  chiefly  noticed  in  those  cases  in  which 
the  function  has  been  established  at  an  early  period.  In 
most  of  those  cases,  however,  in  which  the  function  contin- 
ues to  be  exercised  up  to  the  age  of  53  or  54,  the  period  of 
commencement  has  not  been  unusually  late;  in  such  cases, 
the  menstrual  life  far  exceeds  the  average  of  thirty  years. 

Dr.  Beigel,*  the  able  editor  and  translator  of  the  two 
former  German  editions  of  this  work,  gave  this  observation 
on  500  cases:  of  126  cases  where  menstruation  had  ceased, 
there  were  9  cases  of  late  menstruation. 

Menstruation  ceased  at  51  in  i  case 

52  "  2     " 

53  "  I     " 

54  "  I     " 

55  "  2     " 

Periodicity. — The  usually  accepted  statement  is  that  the 
time  included  between  the  day  of  the  appearance  of  the 
discharge  and  the  corresponding  subsequent  day  is  twenty- 
eight  days — a  lunar  month;  but  the  difference  presented  by 
individual  cases  in  this  respect  is  so  great  as  to  show  that 
any  rule  generally  applicable  must  have  rather  a  wide 
range.  Many  women  menstruate  regularly  every  three 
weeks;  and  a  less  number  menstruate  every  calendar 
month,  or  a  little  over.  In  another  class  of  women  there 
is  great  irregularity,  the  period  varying  from  time  to  time 
consistently  with  health.  It  is  only,  then,  in  the  majority 
of  instances  that  menstruation  occurs  every  lunar  month. 
There  is  often  evidence  that  peculiarities  in  respect  to  the 
menstrual  period  are  transmitted  from  one  generation  to 
another. 

Number  of  Days  duritig  which  Ihe  Discharge  continues. — In 
562  cases  examined  by  IBrierre  de  Boismont,  the  discharge 
continued  8  days  in  172  individuals;  the  number  of  days 
next  frequently  observed  was  3;  the  next  4.  The  conclu- 
sion arrived  at  by  this  author  was  that  the  menstrual  flow 

*  German  edition  of  this  work  (Enke,  Erlangen),  p.  245. 


HISTORY    OF   THE    UTERUS   AND    OVARIES.  59 

continues  longer  in  towns  than  in  the  country;  and  longer 
in  small,  nervous,  delicate  women,  than  in  those  who  are 
tall,  robust,  and  of  a  sanguine  temperament;  longer  also  in 
those  who  lead  a  sedentary,  easy,  voluptuous  life  than  in 
those  who  follow  active  occupations,  whose  diet  is  condu- 
cive to  health,  and  whose  habits  are  regular.*  In  women 
who  are  beginning  to  menstruate,  the  discharge  lasts  gen- 
erally a  short  time  for  the  first  few  months,  its  duration  in- 
creasing subsequently.  The  time  during  which  the  dis- 
charge continues  is,  in  general  terms,  three  to  seven  or 
eight  days;  but  the  observer  must  be  prepared  to  meet 
with  great  variations  in  this  particular. 

Quantity. — Late  observers  (Magendie  excepted)  consider 
the  typical  quantity  of  sanguineous  fluid  which  is  lost  at 
each  period  to  be  three  to  four  ounces,  or  even  less  than 
this.f  The  older  estimates  considerably  exceed  this  in 
amount.  The  quantity  appears  to  be  greatest  about  the 
middle  of  the  period  in  the  majority  of  cases.  Sudden  ces- 
sation for  some  hours  together,  followed  by  copious  dis- 
charges, whether  accompanied  by  coagula  or  not,  is  ab- 
normal; for  when  there  is  no  impediment  the  flow  continues 
persistently  and  uninterruptedly,  though  it  may  be  more  in 
quantity  at  one  time  of  the  day  than  another. 

Quality  of  the  Fluid  dischar^:;ed. — The  researches  of  Dr. 
Whitehead,  Donne,  and  others,  have  conclusively  shown 
that  the  discharge  observed  is  really  composed  of  blood; 
and  that  when  obtained  immediately  from  the  uterus,  and 
before  it  has  been  subjected  to  the  action  of  the  acid  mucus 
of  the  vagina,  it  is  coagulable  just  as  is  ordinary  blood.  As 
an  illustration  of  this  fact  we  find  that,  when  the  menstrual 
flow  is  excessive,  clots  are  not  unfrequently  discharged. 
Ordinarily,  as  it  flows  from  the  vulva,  it  has  acquired  an 
acid  reaction,  and  is  no  longer  coagulable.  For  the  first 
few  hours  the  discharge  is  paler,  it  then  becomes  of  a 
deeper  red,  and  again  appea.-s  of  a  lighter  color  as  it  is 
about  to  disappear.  The  odor  of  the  menstrual  secretion 
is  peculiar;  formerly  extraordinary  effects  were  attributed 
to  it,  which  it  is  unnecessary  to  enumerate  here.  The  vary- 
ing qualities  of  the  vaginal  and  cervical  secretions  have 
l^robably  more  influence  in  altering  the  qualities  of  the 
menstrual  fluid  than  any  varieties  of  the  fluid  itself  as  it 
exudes  from  the  uterus. 


0^.  (it.  p.  143.  f  Farre,  loc.  cit.  p.  663. 


6o  DISEASES   OF   WOMEN. 

CHAPTER  III. 
Examination  of  the  Ui'erus  and  Ovaries. 

Digital  Examination  of  the  Uterus"  from  the  Vagina. — Position 
of  the  Patient. 

Double  Examination  of  the  Uterus. 

Digital  Examination  of  the  Os  Uteri  and  of  tub  Vaginal  Part 
of  the  Cervix  Uteri. — Normal  Condition  of  the  Os  and  Cervix — 
Method  of  Examination — Apparent  absence  of  the  Os  Uteri;  various 
causes — Unusual  Softness  of  the  Os  Uteri  from  Pregnancy  or  other 
Causes — Unusual  Hardness  of  the  Lips  of  the  Os  Uteri;  its  Causes — 
Size  of  the  Os  Uteri — Variations  in  the  Length  of  the  Vaginal  Portion 
of  the  Cervix  Uteri;  Relation  of  Pregnancy  to  this  Condition. 

Examination  of  the  Uterus  by  Means  of  the  Sound. — The  In- 
strument; Method  of  Introduction — Variations  in  the  Length  and  Di- 
rection of  the  Uterine  Canal  detected  by  the  Sound. 

Examination  of  the  Os  Uteri  by  Means  of  the  Speculum. — Gen- 
eral Rules — Method  of  Using  the  Instrument — Description  of  Various 
Instruments. 

Examination  of  the  Ovaries. 

In  order  to  obtain  precise  information  as  to  the  physical 
condition  of  the  uterus  and  ovaries,  a  physical  examination 
is  indispensable.  The  examination  is  made  by  means  of 
the  finger  introduced  into  the  vagina,  sometimes  also  into 
the  rectum,  and  further  information  may  often  be  elicited  by 
means  of  palpation  over  the  hypogastric  region  of  the  ab- 
domen. 

DIGITAL   EXAMINATION    OF    THE    UTERUS    FROM    THE    VAGINA. 

To  practice  digital  examination  of  the  uterus  from  the 
vagina,  the  patient  is  usually  placed  on  the  side.  The  pa- 
tient should  be  laid  on  the  side  close  to  the  edge  of  the 
couch,  and  the  trunk  of  the  body  placed  somewhat  across 
the  couch.  The  knees  should  then  be  drawn  upward,  so  as  to 
be  quite  at  right  angles  to  the  bod3\  This  position  enables  the 
observer  to  reach  with  the  finger  much  higher  in  the  interior 
of  the  pelvis  than  is  possible  in  any  other  way.  It  is  some- 
times necessary  in  cases  of  suspected  pregnancy,  <f.,^.,  to 
examine  the  patient  in  the  standing  position,  in  order  to 
detect  more  readily  increase  in  the  size  and  weight  of  the 
uterus,  the  presence  of  ballottement,  etc.  In  the  case  of 
unmarried  women,  with  an  unruptured  hymen,  digital  ex- 
amination should  not  be  undertaken  unless  there  is  a  rea- 
sonable probability  of  the  existence  of  some  decidedly  ab- 


EXAMINATION   OF   THE    UTERUS   AND    OVARIES.      6t 

normal  condition  of  the  uterus.  On  the  other  hand,  false 
delicacy  should  not  be  allowed  to  operate  so  as  to  prevent 
the  recognition  of  conditions  essential  to  health  and  com- 
fort. In  doubtful  cases  an  examination  by  tiie  rectum  may 
be  made  first,  and  it  can  thus  be  determined  whether 
further  examination  by  the  vagina  is  really  required.  Very 
valuable  information  as  to  the  general  shape  and  position 
of  the  uterus  can  be  thus  procured,  the  septum  between 
the  rectum  and  vagina  being  so  thin  that  the  practiced 
touch  readily  defines  the  uterus  in  this  manner.  Thus  the 
hymen  may  be  entirely  avoided.  It  is  found  that  under 
anaesthetic  influence  the  resistance  offered  by  the  hymen  is 
less,  and  thus  digital  examination  is  facilitated  by  the  use 
of  ether  or  chloroform. 

The  finger  should  be  cleansed  and  covered  with  oil  or 
unguent  before  being  introduced.  The  finger  should  be  in- 
troduced slowly  and  carefully,  and  by  its  means  the  roof, 
the  floor,  and  the  upper  part  of  the  vagina  can  be  succes- 
sively toucheil.  The  cervix  and  os  uteri  are  also  subjected 
to  touch,  and  information  as  to  the  size,  consistence,  shape, 
and  position  of  the  uterus  is  obtained.  Deliberation  and 
care  are  necessary  to  the  proper  conduct  of  the  exploration. 

Ordinarily  the  finger  introduced  into  the  vagina  can  be 
made  to  touch  the  os  and  the  vaginal  part  of  the  cervi.x 
uteri,  but  the  botly  of  the  uterus,  and,  indeed,  the  upper 
part  of  the  cervix,  are  not  in  a  state  of  health  easily  accessi- 
ble by  this  means  of  examination  alone.  To  reach  the 
fundus  anteriorly  the  roof  of  the  vagina  must  be  pushed 
very  firmly  upward,  and  even  then  the  effort  may  not  be 
successful  in  the  normal  state  of  things.  And  it  is  quite 
impossible  to  reach  the  fundus  posteriorly  by  this  method 
of  examination  alone  when  the  uterus  is  in  its  proper  con- 
dition. 

The  digital  examination  of  the  uterus  per  vagina/n  is  by 
far  the  most  valuable  and  important  means  of  acquiring 
information  regarding  its  physical  condition.  Too  much 
attention  can  hardly  be  bestowed  in  acquiring  facility  and 
dexterity  in  this  method  of  examination,  and  it  is  cer- 
tain that  unless  it  be  carefully  practiced  there  is  no  safe- 
guard against  acquiring  erroneous  and  inadequate  notions 
respecting  the  case  before  us.  It  is,  taken  alone,  far  more 
valuable  than  any  other  method  of  exploration  that  can  be 
mentioned,  for  although  other  methods  may  be  required, 
they  are  all  subordinate  to  this — the  digital  examination. 


62  DISEASES   OF    WOMEN. 

By  means  of  the  digital  examination  of  the  vagina  also 
the  condition  of  the  ovaries  can  frequently  be  determined. 
Ordinarily  the  ovaries  are  not  easily  felt  by  the  finger  in- 
troduced as  above  directed,  but  if  the  ovary  on  either  side 
lies  unusually  low  it  can  be  readily  felt  through  the  vaginal 
wall. 

The  physical  exploration  thus  conducted  gives  valuable 
information  respecting  the  presence  or  absence  of  thicken- 
ing, or  hardness,  or  tumors  situated  in  front  of  or  behind 
the  uterus  or  laterally;  and  abnormal  conditions  of  the 
rectum — accumulations  of  faeces,  etc.,  are  often  thus  recog- 
nized when  they  would  have  been  undetected  or  overlooked 
had  this  digital  examination  of  the  vagina  been  omitted. 

Double  Exaviiuation  of  the  Uterus. — There  are  several 
methods  by  which  the  uterus  may  be  more  completely  and 
exacth^  explored. 

1.  The  patient  being  placed  on  the  back  or  laid  on  the 
side  with  the  axis  of  the  body  across  the  couch  or  bed,  the 
forefinger  of  one  hand  is  inserted  in  the  rectum,  and  the 
fingers  of  the  other  hand  placed  above  the  pubes.  Thus 
the  shape  and  size  of  the  intervening  structures  can,  under 
favorable  circumstances,  be  recognized  more  precisely.  This 
method  is  useful  also  in  cases  where  a  vaginal  examination 
is  objectionable. 

2.  Or  the  forefinger  of  one  hand  is  inserted  in  the  vagina, 
and  the  fingers  of  the  other  hand  placed  above  the  pubes. 

3.  Or  a  sound  is  inserted  in  the  bladder,  and  the  finger 
into  the  rectum.  This  method  is  very  serviceable  in  cases 
of  suspected  absence  of  the  uterus. 

4.  A  method  suggested  and  practiced  by  Dr.  Noeggerath, 
of  New  York,  consists  in  dilating  the  urinary  meatus,  in- 
serting the  finger  of  one  hand  into  the  bladder  and  the  fore- 
finger of  the  other  hand  into  the  rectum.  The  shape  and 
size  of  the  uterus  can  be  more  perfectly  and  completely  ex- 
plored in  this  manner  than  in  any  other  way.  Dr.  Noeg- 
gerath has  examined  as  many  as  thirteen  cases  in  this  man- 
ner.* 

The  objection  to  this  method  is  the  necessit}^  for  forcible 
dilatation  of  the  urethra.  This  forcible  dilatation  Dr.  Noeg- 
gerath effects  either  rapidly  at  one  sitting,  using  first  a  steel 
dilator  and  then  metallic  bougies  until  enough  space  is  ob- 
tained  to  admit  the   finger,  or  more  slowly  by  laminaria 

*"  American  Journal  of  Obstetrics,"  vol.  viii.  p.  123. 


EXAMINATION   OF   THE    UTERUS   AND    OVARIES.      63 

tents.  He  found  the  effects  of  the  dilatations  severe  in  six 
cases  (in  all  of  the  six  dilatations,  rapid  under  chloroform), 
producing  frequent  micturition,  burning,  sensations  of  pain, 
and  in  one  case  perimetritis,  but  in  no  case  was  permanent 
bad  result  observed.  The  general  conclusion  to  be  drawn 
from  Dr.  Noeggerath's  experience  would  seem  to  be  that 
this  method  of  exploration  is  valuable,  but  its  employment 
will  probably  be  always  limited  to  very  exceptional  cases. 

5.  Another  means  of  double  examination  consists  in  in- 
troducing one  finger  into  the  rectum  anrl  the  uterine  sound 
into  the  uterus  itself.  The  sound  can  then  be  felt  through 
the  rectum.     (See  Examination  by  the  Sound.) 

DIGHAL    EX.\MIN.\TION    OF    THE    OS    UTKRI    AND    OF    THE 
VAGINAL    PART    OF    THE    CERVIX    UTERI. 

The  size  of  the  orifice  of  the  os  uteri,  its  shape,  the  hard- 
ness or  softness  of  the  lips  of  the  os  and  of  the  adjacent 
structures  of  the  vaginal  portion  of  the  uterus,  are  all  open 
to  considerable  variation,  and  upon  these  variations  con- 
clusions may  be  very  safely  based  as  to  the  nature  of  the 
pathological  or  physiological  alterations  present. 

To  appreciate  the  various  changes  which  are  liable  to 
occur  in  the  condition  of  the  lower  part  of  the  uterus  a 
knowledge  of  the  normal  condition  and  relations  of  the 
parts  is  essential.  The  finger  must  be  educated  to  associate 
a  particular  sensation  with  a  corresponding  condition:  an 
observer  with  an  educated  finger  will  thus  be  enabled  to 
draw  conclusions  wholly  unattainable  by  an  inexperienced 
person.  In  the  words  of  Gooch,  "the  finger  soon  gains  the 
power  of  feeling  when  the  mind  has  acquired  the  knowledge 
of  what  to  feel  for." 

As  preliminary  to  the  discussion  of  this  subject,  some 
account  of  the  normal  condition  of  the  os  and  cervi.x  uteri 
is  necessary. 

"In  the  virgin  and  unimpregnat^d  condition  of  the 
uterus,"  says  Dr.  Montgomery,  "its  mouth  and  the  lower 
section  of  its  neck,  when  examined  by  the  finger  introduced 
into  the  vagina,  can  be  felt,  as  it  were,  projecting  into  that 
cavity  from  a  quarter  to  half  an  inch.  The  part  so  project- 
ing feels  remarkably  firm,  is  slightly  tapering  or  conical  in 
form,  and  about  as  large  as  the  end  of  a  man's  thumi); 
having,  at  its  termination  in  the  vagina,  a  transverse  open- 
ing whose  lips  or  margins  feel  firm  and  well  defined.  Thij 
may  be  so  far  open  as  to  allow  the  extremity  of  the  fing-i' 


64 


DISEASES   OF   WOMEN. 


to  be  insinuated  to  the  deptli  of  an  eighth  or  a  quarter  of 
an  inch,  sometimes  a  little  more,  sometimes  not  so  much; 
or  it  may  merely  communicate  a  sensation  of  a  slight  de- 
pression almost  without  a  cavity,  such  as  is  felt  when  the 
tip  of  the  finger  is  pressed  between  the  lateral  cartilages  at 
the  extremity  of  the  nose.  Sometimes  the  os  uteri  differs 
very  considerably  from  this  description,  being  almost  im- 
perceptible from  its  diminutive  size,  and  perfectly  circular, 
and  it  is  not  very  rare  [here  I  do  not  agree  with  Dr.  Mont- 
gomery, such  a  condition  is  very  rare  in  the  virgin]  to 
find  it  opening  at  once  from  the  upper  extremity  of  the 
vagina  without  any  projection  of  the  cervix  uteri  into  that 
canal,  which  to  the  finger  seems  to  taper  gradually  to  a 
point,  and  there  terminate  in  the  orifice  of  the  womb,  the 
margins  of  which  are  very  indistinctly  felt.  .  .  .  Once  a 

Fn;.   7. 


woman  has  borne  children,  or  sometimes  even  one  child, 
the  conditions  of  the  uterus  are  liable  to  be  altered  in 
several  appreciable  circumstances.  The  whole  organ  is  apt 
to  remain  permanently  larger  than  it  was  originally,  and 
the  cervix  partaking  of  this  change,  is  found  broader,  less 
prominent,  and  less  firm  in  texture,  while  its  shape  is  some- 
times the  reverse  of  that  noticed  in  the  virgin  or  nullipare, 
being  indeed  somewhat  conical,  but  having  the  base  of  the 
cone  downward  instead  of  above;  under  the  same  circum- 
stances the  OS  is  found  of  greater  dimensions,  and  its  open- 
ing much  more  distinctly  transverse,  admitting  more  readily 
the  introduction  of  the  end  of  the  finger,  and  not  unfre- 
qucntly  having  its  circumference  or  margins  uneven,  per- 
haps fissured,  and  giving  the  sensation  of  being  a  little 
lobulated."  * 

*  Op,  cit,  p.  170. 


EXAMINATION    OF   THE    UTERUS  AND   OVARIES.      65 

The  drawing,  copied  from  one  by  Dr.  Farre  (Fig.  7,  p.  64), 
represents  the  orifice  as  having  a  transverse  shape.  The 
transverse  lengtli  of  the  orifice  as  here  shown  is.  1  believe, 
greater  than  it  is  found  to  be  in  the  virgin  os  in  the  major- 
ity of  cases. 

Fig.  8. 


The  patient  being  placed  on  the  side  as  before  directed, 
the  finger  is  then  introduced  into  the  vagina,  the  guide  to 
the  orifice  being  the  great  trochanter;  for  it  will  be  found 


66  DISEASES   OF   WOMEN. 

that  in  the  foregoing  position  tlie  left  hand  being  laid  on 
the  great  trochanter  the  orifice  of  the  vagina  is  immediately 
beneath  it.  A  knowledge  of  this  fact  will  be  found  useful 
in  facilitating  the  necessary  examination. 

It  will  be  borne  in  mind  that  under  <?;-^///«;'j  circumstances 
the  finger  passes  about  the  distance  of  an  inch  before  reach- 
ing the  position  of  the  hymen,  where  the  true  vaginal  canal 
really  begins,  and  the  whole  of  the  forefinger  must  be  in- 
troduced before  the  os  uteri  is  reached.  Where  the  person 
is  very  stout  the  difficulty  of  reaching  the  os  uteri  by  the 
forefinger  is  often  considerable,  and  unless  the  knees  are 
well  drawn  up  it  may  be  impracticable. 

The  drawing,  life-size  (Fig.  8,  p.  65),  exhibits  a  lateral 
view  of  the  interior  of  the  pelvis.  The  straight  line  gradu- 
ated in  inches  shows  the  direction  and  extent  of  an  ordinary 
examination  by  means  of  the  finger. 

The  changes  produced  by  pregnancy  will  be  presently 
described  more  particularly.  The  above  remarks  apply 
only  to  the  uterus  in  the  non-gravid  condition. 

On  examination  it  may  be  found  that  the  uterus  is  a/- 
to^eiher  uianting  (see  chapter  on  Uterine  Malformations). 
The  vaginal  part  of  the  cervix,  as  already  remarked,  is  gen- 
erally shortened  in  women  who  have  had  children;  in  some 
cases  it  almost  entirely  disappears.  It  occasionally  happens 
that  in  such  cases  the  os  uteri  becomes  occluded,  and  no  opening 
can  be  found.  Cases  have  been  recorded  of  women  who 
were  pregnant,  and  in  whom  this  occlusion  had  occurred 
apparently  soon  after  conception,  an  incision  in  the  lower 
part  of  the  uterus  having  been  rendered  necessary  in  order 
to  effect  delivery.  It  may  be,  then,  that  the  os  uteri  is  not 
to  be  felt  because  it  has  become  occluded  in  the  above  man- 
ner; but  the  signs  of  pregnancy  would  under  such  circum- 
stances be  observed;  or  it  may  be  that  the  os  is  situated  un- 
usually high,  and  is  not  readily  reached,  as  is  the  case  more  or 
less  in  the  last  month  or  two  oi  pregnancy :  there  the  pres- 
ence of  pregnancy  should  suggest  the  explanation.  Or  the 
vagina  fnay  have  become  varro^ved  and  constricted  \ij  inflamma- 
tory adhesions  (after  a  difficult  labor),  and  may  appear  to 
terminate  lower  down  than  is  really  the  case.  Abnormities 
of  the  hymen  may  lead  to  a  like  erroneous  inference. 

In  retroversion  of  the  gravid  uterus  the  cervix  uteri  is  often 
thrown  up  so  high  behind  the  pubic  sj^mphysis  that  no  os 
can  be  felt.     The  same  result  may  occur  when  large  tumors^ 


EXAMINATION   OF   THE    UTERUS   AND    OVARIES.      ()^ 

fibroid,  ovarian,  etc.,  occupy  the  pelvis,  lifting  the  os  out  of 
its  place  and  so  preventing  its  being  felt  by  the  finger. 

Softness  of  the  Lips  of  the  Os  Uteri. — The  physical 
conditions  of  the  os  uteri  described  as  "hardness"  or  "  soft- 
ness" are  perhaps  the  most  important  to  which  attention 
can  be  directed.  Normally,  the  textures  of  the  os,  under 
which  term  we  may  conveniently  include  the  parts  sur- 
rounding the  aperture,  are,  in  the  virgin,  firm  and  resistant, 
and  a  peculiar  impression  is  conveyed  to  the  finger  hardly 
to  be  described  in  words.  This  is  to  be  considered  as  its 
typical  physical  condition,  and  it  is  necessary  to  be  familiar 
with  it  in  order  to  be  able  to  detect  variations  from  the 
healthy  state. 

Pregnancy. — Unusual  softness  of  the  os  uteri  and  of  its 
vaginal  part  is  one  of  the  signs  of  pregnancy,  and,  as  such, 
deserves  special  and  particular  mention  in  this  place.  It  is 
a  peculiar  kind  of  softness,  giving  the  sensation  of  a  soft 
te.xture  overlying  a  harder  one,  and  imparting  a  cushiony 
elastic  feel,  quite  characteristic.  It  has  been  well  compared 
to  the  sensation  given  to  the  finger  when  pressed  into  the 
glans  penis  in  a  state  of  erection.     The   surface  of   the  lips 

Fig.  9. 


^; 


of  the  OS  are  at  the  same  time,  in  primiparae,  smooth  and 
uniform;  in  multiparae  there  may  be  fissures  giving  the  lips 
a  slightly  lobulated  arrangement.  As  regards  the  period  of 
l)regnancy  at  which  this  peculiar  softness  is  observed,  it  is 
present  during  tlie  second  month  pretty  distinctly,  but  not 
so  distinctly  at  this  early  period  in  primiparae  as  in  women 
who  have  already  borne  children.     At  the  end  of  the  third 


68  DISEASES   OF  WOMEN. 

or  fourth  month,  however,  the  softness  of  the  os  uteri  Is 
ver)^  distinct  in  most  cases,  and,  what  is  very  important, 
the  softness  becomes  associated  at  about  the  fifth  month, 
and  subsequently,  with  a  peculiar  shotty  feel,  arising  from 
the  muciparous  glands  around  the  os  uteri  becoming  en- 
larged. Moreover,  the  softness  becomes  intensified  as  preg- 
nancy advances:  in  many  cases  I  have  found  the  lips  in  an 
almost  spongy  condition,  from  extreme  softness,  near  the  end 
of  pregnancy.  The  existence  of  this  softness,  and  of  other 
physical  changes,  in  the  vaginal  portion,  forms  a  very  strong 
presumption  in  favor  of  the  presence  of  pregnancy.  This 
is  well  shown  in  Fig.  9  from  a  drawing  by  Dr.  Farre.  The 
softness  alone,  or  a  condition  which  at  all  events  closely 
simulates  it,  is  observed  under  other  circumstances  than 
pregnancy.  The  menstrual  nisus  is  attended  with  a  certain 
degree  of  softness  of  the  part;  but  this  could  hardly  mis- 
lead the  observer  if  care  were  taken  to  make  a  second  ex- 
amination after  the  interval  of  a  fortnight  fiom  the  date  of 
the  first.  Distension  of  the  uterus,  owing  to  the  presence 
of  fluid,  a  large  polypus,  hydatidiform  degeneration  of  the 
ovum,  may,  each  or  either  of  them,  give  rise  also  to  soften- 
ing and  fulness  of  the  os  in  some  degree  simulating  that 
due  to  pregnane)'.  In  cancer  of  the  cervix  uteri  there  may  be 
sofrness  due  to  the  presence  of  fungous  growths,  having  a 
soft  consistence,  but  in  this  case  there  is  also  irregularity  of 
the  surface. 

As  Montgomery  observes,  this  softness  of  the  os  is  most 
reliable  from  a  negative  point  of  view;  thus,  if  the  patient 
were  supposed  to  be  five  months  advanced  in  pregnancy, 
the  absence  of  the  softening  \\ould  be  strongh' against  such 
a  supposition.  This  statement  does  not  hold  good  in 
cases  of  cancer  of  the  cervix  uteri;  in  such  cases  there 
might  be  an  absence  of  softness,  and  the  patient  might  yet 
be  pregnant.  In  ordinary  cases,  however,  the  presence  or 
absence  of  this  softening  of  the  os  and  vaginal  portion  is 
extremely  valuable  from  a  diagnostic  point  of  view. 

Softness  of  the  os  is  observed  in  cases  of  cauliflower  ex- 
crescence of  the  OS  uteri.  The  softness  due  to  this  cause  is, 
however,  associated  with  a  lobular  enlarged  condition  of  the 
lips  and  margins  of  the  os  uteri,  eminently  characteristic  of 
the  affection.  In  the  very  early  stage  of  this  affection,  how- 
ever, when  the  lips  of  the  os  are  not  much  enlarged,  this 
softness  might,  by  a  beginner,  be  possibly  mistaken  for  that 
due  to  pregnancy. 


EXAMINATION   OF   THE   UTERUS   AND   OVARIES.      69 

The  question  as  to  the  presence  of  undue  softness  of  the 
OS  uteri  is  important  in  relation  to  the  cojidition  of  tiutrition 
of  the  organ.  In  anotlier  chapter  it  will  be  explained  that 
one  of  the  more  important  physical  changes  the  uterus  un- 
dergoes in  cases  of  disease  is  a  lessening  of  the  proper 
hardness  of  the  tissues,  resulting  in  a  condition  of  unusual 
softness  of  the  cervix  appreciable  to  the  touch  on  digital 
examination. 

Hardness  cannot  be  said  to  be  diagnostic  per  se  of  any 
particular  disease  of  the  uterus.  Normally,  the  degree  of 
iiardness  presented  to  the  touch  is  consiilerable,  and  if  the 
shape  and  size  of  the  os  and  of  the  vaginal  portion  be  not 
altered,  the  hardness  alone  is  not  significant.  It  would, 
however,  enable  us  to  decide  against  the  presence  of  preg- 
nancy in  a  case  supposed  on  other  grounds  to  have  gone  as 
far  as  the  fourth  or  fifth  month.  Conjoined  with  ^j/Zr^r  phy- 
sical changes  in  the  vaginal  portion,  irregularity,  hyper- 
trophy, etc.  (see  cliapters  on  Cancer  of  the  Uterus,  Fibroid 
Tumor,  etc.),  it  may  become  positively  significative  of  other 
important  conditions. 

The  OS  uteri  is  occasionally  found  to  convey  to  the  touch 
an  impression  as  if  hard  rounded  masses  like  shot,  of  vari- 
able size,  were  imbedded  in  it.  These  bodies  are  the  follic- 
ular glands  of  the  part  distended  with  accumulated  secre- 
tion. It  has  been  already  mentioned  that  during  pregnancy 
rounded  bodies  are  usually  found  to  be  present  in  the  sub- 
stance of  the  cervix,  and  there  seems  to  be  an  identit)'  be- 
tween the  bodies  in  question  and  those  occasionally  met 
with  in  this  portion  under  other  circumstances,  which  may 
attain  a  larger  size,  and  which  have  been  termed  by  several 
writers  Oiiila  Xabotlii*  And  in  cases  where  small  cysts  are 
found  growing  from  the  os,  these  cysts  appear  to  have  alike 
origin. 

Size  of  thk  Os  Uteri. — In  the  virgin,  the  uterus  being 
healthy,  the  aperture  is  large  enough  to  be  just  perceived 
by  the  touch.  In  the  pregnant  uterus  the  orifice  enlarges, 
and  at  the  fifth  month  is  nearly  large  enough  to  admit  the 
point  of  the  finger.  In  the  latter  case,  this  enlargement  of 
the  orifice  is  Associated  with  softening  of  the  lips  of  the  os, 
with  the  presence  of  the  muciparous  glands,  uterine  tumor, 
etc.     When  the  orifice  is  so  large  as  to  admit  the  finger,  soft- 

*Sonie  remarks  on  the  nature  of  these  bodies  will  be  found  in  Dr. 
Tyler  Smith's  work  "On    Leucorrhoea,"  p.  143. 


70  DISEASES   OF   WOMEN. 

ness  being  absent,  this  increase  in  size  may  be  dependent 
on  one  of  the  several  following  conditions: — In  cases  of  large 
fibrous  tumors  of  the  uterus  encroaching  on  the  cavit}',  tlic 
lips  are  separated  to  a  considerable  extent,  but  they  are 
hard  and  firm.  Such  is  also  more  usually  the  case  where 
polypus  of  the  uterus  of  large  size  is  present.  The  separa- 
tion of  the  lips  occurs  earlier  in  polypus  than  in  cases  of 
fibrous  tumor. 

The  OS  is  also  widely  open  in  cases  of  enlargement  of  the 
uterus  due  to  deficient  involution  of  the  organ  after  deliv- 
ery. In  women  who  have  been  recently  delivered,  an 
open  condition  of  the  os  is  necessarily  present  and  is  a  very 
valuable  sign  in  cases  where  evidence  of  recent  delivery  is 
required  for  medico-legal  purposes.  Under  such  circum- 
stances, also,  the  condition  of  the  os  uteri  is  in  other  re- 
spects peculiar.  It  is  soft,  flabby,  and  relaxed.  The  open 
condition  of  the  os  gradually  diminishes  after  labor,  so  that 
after  two  or  three  weeks  this  sign  is  no  longer  useful:  in 
cases  where  abortion  has  occurred,  the  open  state  of  the  os 
is  less  marked,  and  it  is  a  less  decisive  test  than  when  de- 
livery has  taken  place  at  full  term.*  The  subsequent  pro- 
gressive closure  of  the  os  is  a  valuable  diagnostic  sign  in 
tliese  cases.     (See  also  Examination  by  the  Sound.) 

An  open  condition  of  the  os  is  found,  often  to  a  marked 
extent,  in  cases  where  the  uterus  is  enlarged  from  the  pres- 
ence of  chronic  congestion.  In  cases  of  leucorrhoea  con- 
nected with  an  increased  action  of  the  numerous  glands  of 
the  cervix  uteri,  the  os  is  open  more  widely  than  usual.  In 
cases  of  cancer  of  the  uterus,  the  aperture  is  often  much 
larger  than  it  should  be,  and  the  first  stage  of  this  disease 
has  in  this  respect  a  great  similarity  to  other  conditions  of 
less  serious  import.  But  in  cases  of  cancer  of  the  os  uteri, 
the  opening  has  lost  its  symmetrical  shape:  there  is,  more- 
over, irregularity,  of  a  kind  to  be  particularly  described 
presently. 

On  the  other  hand,  the  opening  of  the  os  may  be  too  small, 
or  altogether  wanting.  If  there  be  any  reason  to  suspect 
that  either  of  these  conditions  be  present,  as  in  cases  of  ster- 
ility, dysmenorrhoea,  etc.,  etc.,  it  will  be  necessary  to  resort 
to  another  method  of  examination,  and  to  use  the  uterine 
sound  as  a  probe.     (See  Examination  by  Sound.) 

*  .\  most  valuable  chapter.  On  the  Signs  of  Delivery,  will  be  found  in 
Montgomery's  work,  Jam  cit.  p.  573. 


fiXAMINATION   OF  THE   UTERUS  AND   OVARIES.      7 1 


Fig.  io. 


It, 


Lacerations  of  the  cervix  owing  to  injury  during  parturi- 
tion are  recognizable  by  the  touch. 

Length  of  the  Vaginal  Portion. — Variations  in  re- 
spect to  the  vaginal  portion  of  the  cervix  are  important 
from  a  diagnostic  point  of  view.  In  pre^:^nanc\  there  is  a 
diminution  in  the  length  of  the  vaginal  portion,  the  nature 
and  degree  of  which  must  be  now  explained.  In  the  first 
place,  it  is  a  mistake  to  suppose  that  there  is  a  perfect 
regularity  in  the  degree  to  which  the  abbreviation  of  the 
vaginal  portion  proceeds  at  the  same  period  of  pregnancy 
in  all  instances  ;  in  the  second  place,  it  must  be  recollected 
that  comparative,  not  positive,  measurements  only  are  to  be 
relied  on.  In  order  that  we  may  draw  correct  conclusions 
in  particular  cases,  it  is  necessary  to  be  aware  of  the  normal 
length  of  the  vaginal  portion  in  the  case  before  us;  after 
repeated  pregnancies,  the 
portion  of  the  cervix  pro- 
jecting into  the  vagina  be- 
comes shorter  and  shorter. 
Normally,  the  vaginal  por- 
tion begins  to  be  reduced 
in  length  about  the  fourth 
month  of  pregnancy,  and 
as  pregnancy  advances  the 
shortening  also  progresses, 
until  at  full  term  the  whole, 
or  very  nearly  ilie  whole,  of 
the  vaginal  portion  has  been 
drawn  up  out  of  the  vagina.  The  length  of  the  cerv'ix  it- 
self is  very  little  altered  during  pregnancy;  the  apparent 
shortening  is  due  to  drawing  up  of  the  cervix  out  of  the 
vagina,  which  process  has  the  effect  of  reducing  the  length 
of  the  vaginal  portion.*  Fig.  lo,  copied  from  Dr.  Farre's 
drawing,  shows  the  extent  to  which  the  abbreviation  of 
the  vaginal  portion  proceeds  at  the  eighth  month  of  preg- 
nancy. 

This  shortening  becomes  useful  as  diagnostic  of  preg- 
nancy when  the  patient  is  under  observation  for  some 
months,  and  it  can  be  ascertained  from  time  to  time  that  a 
progressive  shortening  is  actually  taking  place.  If  the  other 
signs  present  be   not  against   pregnancy,  this  is  one  of  the 


fact. 


Dr.  Matthews  Duncan  first  forcibly  drew  attention  to  this  important 


72  _  DISEASES   OE  WOMEN. 

strongest  proofs  in  its  favor.  Enlargement  of  the  utefuS 
and  softening  of  the  os  uteri  would,  under  such  circum- 
stances, be  associated  with  it.  The  vaginal  portion  may 
be  found  actually  shortened  from  several  other  causes — 
previous  pregnancies,  dislocation  of  uterus  upward  by 
ovarian  tumors,  distension  of  uterus  by  large  polypus  or 
by  fluid,  as  in  cases  of  hydrometra,  also  from  dragging  of 
the  uterus  upward  by  large  fibrous  tumors  of  the  uterus. 
In  cases  of  extra-uterine  pregnancy  the  shortening  is  want- 
ing.    (Kiwisch  ) 

EXAMINATION    OF    THE    UTERUS    BY    MEANS    OF    THE    SOUND. 

"It  is  possible,"  says  Sir  James  Y.  Simpson,  through 
whom,  in  this  country  at  least,  the  use  of  the  instrument 
became  known,  "by  the  use  of  a  uterine  sound  or  bougie 
introduced  into  the  uterine  cavity,  to  ascertain  the  exact 
position  and  direction  of  the  bod}'^  and  fundus  of  that 
organ;  to  bring  these  higher  parts  of  the  uterus,  in  most 
instances,  within  the  reach  of  tactile  examination;  and  to 
ascertain  various  important  circumstances  regarding  the 
OS,  cavity,  lining  membrane,  and  walls  of  the  viscus." 

The  sound  itself  is  a  slender  rod  of  flexible  metal,  termi- 
nated by  a  slight  knob  at  one  end  and  by  a  flat  handle  at 
the  other.  It  is  graduated  in  inches,  and  at  2\  inches  from 
the  bulbed  end  it  is  customary  to  place  a  slight  projection. 
The  instrument  is  verj'  slightly  curved  at  this  point.  The 
bulbed  extremit}'  has  a  diameter  of  one  eighth  of  an  inch. 
A  second  instrument  provided  with  a  much  smaller  bulbed 
extremity  is  sometimes  useful. 

This  instrument  must  never  be  used  without  a  previous 
digital  examination,  and  there  are  circumstances  under 
which  the  uterine  sound  is  not  to  be  used  at  all — that  is  to 
say,  where  there  is  the  slightest  reason  for  suspecting  that 
the  patient  is  pregnant.  The  introduction  of  the  sound 
into  the  uterus  under  these  circumstances  would  almost  in- 
evitably occasion  miscarriage  or  abortion.  In  cases  where 
the  patient  is  the  subject  of  amenorrhoea,  this  caution  is 
particularly  appropriate;  for  during  the  early  montlis  of 
pregnancy  she  is  sometimes  unaware  of  her  condition, 
or  desirous  of  concealing  the  fact  when  known  to  her. 
Under  such  circumstances  the  sign  on  which  it  is  customary 
to  place  most  reliance  in  deciding  as  to  the  propriety  or 
not  of  using  the  sound  is  the  presence  or  absence  of  softness 


EXAMINATION   OF   THE    UTERUS   AND   OVARIES.      73 


of  the  vaginal  portion  of  the  cervix  and  of  the  edges  of  the 
OS  uteri;  and,  where  tlie  softness  in  question  is  detected, 
to  refrain  from  using,  or  at  all  events  to  postpone  the  use 
of,  the  instrument  until  the  nature  of  the  case  is  made  more 
evident  in  other  ways.  As  it  must  be  admitted,  however, 
that  the  presence  or  absence  of  this  sign  is  by  no  means  a 
positively  sure  criterion,  unless  perhaps  in  very  experienced 

Fic.  ii.» 


hands,  it  will  not  be  safe  to  rely  exclusively  upon  it:  it  will 
be  better  in  a  case  where  there  is  the  slightest  doubt  to  be 
on  the  safe  side. 

Another  caution  is  required.  It  is  not  so  very  uncommon 
for  women  to  suffer  from  slight  losses  of  blood  at  the  be- 
ginning of  pregnancy;  such  losses  might  be  readily  taken 

*  Fig.  II  represents  the  sound  completely  introduced,  the  position  of  the 
uterus  normal. 


74  DISEASES   OF   WOMEN. 

to  be  evidence  of  menstruation,  and  the  sound  might  in 
such  cases  be  injuriously  used. 

It  has  occasionally  happened  that  the  sound  has  been  in- 
troduced into  the  pregnant  uterus,  and  no  evil  result  has 
followed.  It  is  thus  shown  that  the  instrument  may  pass 
into  the  decidual  cavity  between  the  decidua  uterina  and 
decidua  refiexa  without  necessarily  inducing  abortion. 

As  a  general  rule,  patients  experience  no  inconvenience 
from  the  use  of  the  sound,  if  it  be  carefully  introduced;  but 
in  a  few  cases  the  passage  of  the  instrument  gives  great 
pain,  and  its  use  should  not  then  be  persevered  in. 

Method  of  Introductio7i. — The  patient  is  conveniently  placed 
for  the  use  of  the  sound,  either  lying  on  the  left  side  close 
to  the  edge  of  a  high  couch  or  bed,  or  lying  on  the  back; 
as  a  general  rule,  the  former  position  is  preferable.  The 
forefinger  of  the  right  hand  is  first  introduced  into  the 
vagina,  and  the  tip  of  the  finger  brought  into  contact  with 
the  OS  uteri.  The  uterine  sound,  previously  warmed  and 
oiled,  is  then  lightly  grasped  by  the  left  hand,  and  the 
point  of  the  instrument  carried  slowly  toward  the  os  uteri, 
the  forefinger  of  the  right  hand  being  made  use  of  as  a 
director.  If  these  directions  be  well  attended  to,  the  point 
of  the  instrument  is  readily  made  to  hit  the  orifice  through 
which  it  is  desired  to  pass.  When  the  point  of  the  instru- 
ment is  engaged  in  tlie  os  uteri,  the  first  part  of  the  opera- 
tion is  completed. 

[The  advocates  of  mechanical  pathology  and  mechanical 
treatment  of  misplacements  sometimes  make  the  mistake 
of  not  using  the  speculum.  I  have  seen  cases  that  had 
been  treated  by  pessaries  for  months,  where  there  was 
eversion  and  erosion  of  the  cervical  membrane  and  other 
inflammatory  condiulons,  that  were  speedily  curable  alone 
by  a  different  and  appropriate  treatment.  It  is  well  to  use 
every  method  for  correct  diagnosis.] 

The  passage  of  the  sound  through  the  canal  of  the  cervi.x 
and  into  the  cavity  of  the  body  of  the  uterus  requires  ver)'' 
careful  management,  and  occasionally  is  only  to  be  accom- 
plislied  by  those  possessed  of  considerable  dexterity.  It  is 
imperatively  necessary  to  bear  in  mind  that  the  introduc- 
tion of  the  sound  should  be  accomplished  without  using  the 
smallest  degree  of  force.  Ordinarily,  if  the  operator  has 
introduced  the  sound  in  the  proper  direction,  the  curvature 
of  the  instrument  and  the  curvature  and  direction  of  the 
canal  being  identical,  the  instrument  is  easily  made  to  pass 


EXAMINATION   OF  THE    UTERUS  AND   OVARIES.      75 

upward  until  the  knobbed  extremity  reaches  tlie  fundus 
uteri.  Normally,  the  canal  of  the  uterus  passes  at  first  up- 
ward in  the  direction  of  the  pelvic  axis,*  but  higher  up 
there  is  a  slight  inclination  forward.  As  a  matter  of  prac- 
tice I  find  it  best  to  use  a  sound  which  is  really  almost 
straight,  as  represented  in  the  figure.  It  is  a  great  mistake 
to  use  an  instrument  sharply  curved.  If  the  uterus  be  of 
the  average  size,  the  instrument  can  be  introduced  2J  inches 
beyond  the  os  uteri,  and  the  projecting  elevation  on  the 
convex  side  of  the  curve  of  the  sound  is  felt  by  the  fore- 
finger to  coincide  with  the  os  uteri.  When  the  sound  has 
been  introduced  a  couple  of  inches,  greater  care  is  required 
in  pushing  it  onward.  It  occasionally  happens  that  the  tis- 
sue of  the  uterus  is  diseased,  and  so  soft  that  an  instrument 
such  as  the  uterine  sound  may  be  driven  through  the  fundus 
by  the  exercise  of  very  little  force.  The  advisability  of 
avoiding  all  risk  of  such  an  accident  need  not  be  enlarged 
upon. 

The  sound  is  sometimes  used  through  the  speculum.  It 
is  far  preferable,  however,  to  introduce  the  sound  in  the 
manner  above  described;  I  believe  that  there  is  far  more 
risk  of  doing  injury  to  the  uterus  when  the  sound  is  used 
in  conjunction  with  the  speculum.  [Place  the  patient  in 
the  left  lateral  semiprone  position  (Sims),  introduce  the 
Sims  speculum,  then  pull  the  cervix  gently  forward  and 
hold  it  firmly  with  a  small  tenaculum,  and  the  sound  may 
be  used  with  impunity.] 

Supposing  that  an  impediment  is  encountered  to  the  in- 
troduction of  the  instrument,  this  may  proceed  from  one  of 
the  following  causes: 

The  Point  of  the  Instrument  is  not  directed  in  the  Axis  of  the 
Canal. — This  is  the  most  common  cause  of  difficulty,  and  it 
is  one  which  is  only  to  be  got  over  by  practice.  It  is  often 
necessary  to  withdraw  the  instrument  and  bend  it  so  as  to 
give  it  a  different  curve.     If  the  actual  direction  of  the  vagi- 


*  The  question  as  to  what  is  the  normal  direction  of  the  uterine  canal 
has  excited  much  discussion.  I  believe  that,  as  stated  in  the  text,  it  is 
gently  curved,  the  direction  closely  approaching  that  of  a  line  passing 
successively  throuph  the  a.xes  of  the  brain  and  of  the  cavity  of  the  pelvis. 
Dr  Meadows,  who  has  written  a  careful  criticism  on  the  subject  (Lancft, 
i868.  v"i.  ii.  p.  71),  believes  that  the  canal  is  "  straipht  throughout  its 
coarse,  its  axis  being  identical  with  that  of  the  pelvic  brim  or  inlet."  See 
further  remarks  in  chapters  on  Flexions. 


'j(>  DISEASES   OF   WOMEN. 

nal  portion  of  the  cervix  be  previously  ascertained  by  digi- 
tal examination,  this  difficulty  is  less  likely  to  occur. 

The  Os  is  not  pervious  to  the  Instruvieiit. — This  is  a  cause  of 
difficult}^  which  is  generally  anticipated  by  digital  exami- 
nation, for  the  practiced  touch  easily  recognizes  the  pres- 
ence or  absence  of  the  depression  and  opening  of  the  os 
uteri.  In  cases  where  the  finger  fails  to  find  an  aperture, 
it  is  necessary  to  have  recourse  to  the  speculum,  in  order 
to  ascertain  by  actual  inspection  of  the  part  whether  a  mi- 
nute opening  can  be  detected.  The  absence  of  an  opening 
^  is  rare;  such  a  condition  is,  in  most 

instances,  a  congenital  one,  and 
the  patient  has  never  menstruated. 
In  a  few  cases,  however,  the  os  be- 
comes sealed  up,  no  trace  of  its 
existence  being  observed,  in  wo- 
men who  have  had  children,  and 
also,  rarely,  in  women  who  have 
been  subjected  to  operations  the 
nature  of  which  is  such  as  to  lead 
to  contraction  of  the  tissues  around 
the  OS  uteri. 

Contraction  of  the  Canal  of  the 
Cervix. — When  the  instrument  is 
engaged  in  the  canal,  its  further 
passage  may  be  prevented  by  con- 
traction of  the  canal  itself.  It  is 
not  very  common  to  meet  with  an 
obstruction  to  the  passage  of  the 
instrument,  from  this  cause  at 
least,  lower  down  than  i  inch  or 
\\  inch  from  the  os  uteri,  although 
the  occasional  existence  of  con- 
traction at  this  point,  congenital 
or  acquired,  is  not  to  be  denied. 
The  cavity  of  the  cervix  uteri  is  tolerably  capacious,  but  at 
its  superior  termination — the  internal  os — the  canal  is  ordi- 
narily narrowed;  and  in  the  nulliparous  uterus  it  is  custo- 
mary to  find  that  when  the  instrument  reaches  the  point  of 
junction  of  the  cavity  of  the  cervix  and  the  cavity  of  the 
body  of  the  uterus,  there  is  a  slight  resistance.  The  nature 
and  kind  of  resi^ance  here  alluded  to  will  be  better  under- 
stood by  reference  to  Fig.  12,  copied  from  an  exceedingly 
accurate  drawing  by  Dr.  A.  Farrc.     It  represents  a  section 


EXAMINATION   OF   THE    UTERUS   AND   OVARIES.      JJ 

of  the  uterine  cavity,  and  the  extent  and  direction  of  the 
cervical  canal.  In  women  who  have  had  children,  however, 
this  kind  of  difficulty  no  longer  exists.  Without  exercising 
anything  like  forcible  pressure,  any  ordinary  resistance  is 
readily  got  over.  It  requires  care  to  discriminate  between 
contraction  and  those  other  conditions  which  may  impede 
the  progress  of  the  instrument,  next  to  be  alluded  to. 

The  Point  of  the  Instrument  may  become  engaged  in  one  of 

Fig.  13.* 


the  Lacunce  or  Depressions  of  the  Cervix  Uteri  and  its  further 
progress  arrested  thereby.  This  is  one  of  the  most  common 
causes  of  difficulty  in  introducing  the  uterine  sound.  By 
gently  withdrawing  the  instrument  and  again  introducing 
it,  at  the  same  time  slightly  altering  the  direction  in  which 
it  is  pointed,  this  difficulty  wilj  be  readily  overcome. 


pig.  ;3  represent?  retroflexion  of  the  uterus, 


78  DISEASES   OF   WOMEN. 

The  point  of  the  instrument  may  be  arrested  by  the  cxisf- 
ence  of  curvature  or  distorlion  of  the  canal  of  the  uterus.  When 
the  uterus  is  benl  backward  (retroflexion)  or  forward  (ante- 
flexion), the  instrument  is  stopped  abruptly  at  the  seat  of 
the  flexure.  When  the  resistance  met  with  is  due  to  retro- 
flexion, a  tumor  may  be  felt  behind  the  upper  part  and 
back  of  the  vagina — the  fundus  uteri;  and  it  is  necessary, 
before  introducing  the  sound,  to  turn  it  so  that  the  concav- 
ity is  directed  not  forward,  but  backward.  With  a  little 
management,  the  sound  then  passes  round  the  curved  part 
of  the  uterine  canal,  and  backward  into  the  centre  of  the 
fundus  uteri.  In  like  manner,  in  the  case  of  anteflexion, 
the  obstacle  to  the  introduction  of  the  sound  is  to  be  re- 
moved by  giving  the  instrument  a  sharper  curve  forward 
than  usual,  the  concavity  in  this  case  being  directed  an- 
teriorly or  by  pressing  the  handle  backward.  Further  re- 
marks on  the  subject  of  the  use  of  the  sound  when  the 
uterus  is  flexed  will  be  found  in  the  chapters  on  Flexions 
of  the  Uterus. 

In  cases  when  the  sound  does  not  readily  pass,  it  is  a  good 
plan  to  use  the  speculum,  to  draw  the  anterior  lip  of  the  os 
down  gently  by  means  of  a  small  tenaculum,  and  then  to 
introduce  the  sound.  The  canal  is  thus  drawn  more  nearly 
straight  and  the  entry  of  the  sound  facilitated  (see  Fig.  15). 

In  the  use  of  the  sound  we  have,  of  course,  a  very  com- 
plete and  easy  method  of  measuring  the  /crgih  of  the  cavity 
of  the  uterus.  These  variations  are  themselves  signs  of 
great  value  in  the  diagnosis  of  uterine  disease;  the  deduc- 
tions to  be  drawn  therefrom  are  now  to  be  pointed  out. 
Pi-ofessor  Simpson  has,  in  one  of  his  original  memoirs  on 
the  uterine  sound,  so  fully  considered  this  branch  of  the 
subject  as  to  leave  little  to  be  added.  I  have  chiefly  fol- 
lowed tiie  account  given  in  the  memoir  in  question.  The 
usual  length  of  the  uterine  canal  from  the  os  to  the  fundus 
is  2^  inches,  but  a  slight  increase  or  a  slight  diminution  of 
this  measurement  {e.g.,  to  the  extent  of  \  inch)  is  very  fre- 
quently observed,  and  quite  consistently  with  the  uterus 
being  in  a  healthy  state. 

THE  LENGTH  OF  THE  UTERINE  CANAL  GREATER  THAN 
USUAL. 

This  may  be  caused  by  any  one  of  the  following  condi- 
tions: 

Recent  Delivery. — If  the  woman  has  had  a  child,  the  in- 


EXAMINATION   OF  THE    UTERUS   AND   OVARIES.      79 

creased  length  may  be  due  to  a  persistence  of  the  hyper- 
trophy with  which  the  uterus  is  affected  in  consequence  of 
pregnancy.  After  dehvcry  tlie  uterine  cavity  measures  from 
six  to  eight  inches,  and  this  measurement  is  found  grad- 
ually to  diminish,  until  after  six  or  eight  weeks  it  resumes, 
under  ordinary  circumstances,  its  previous  size. 

Lo/i_s:itii(ii'ial Hypcrtrop/iy  0/  the  [/tents  \s  another  condition 
of  the  organ  in  which  the  sound  passes  inward  for  a  greater 
distance  than  usual.  This  species  of  hypertrophy  occurs 
quite  independently  of  pregnancy.  For  the  most  part  the 
cervix  of  the  uterus  is  the  portion  affected:  this  is  length- 
ened out  and  extended,  whereas  the  cavity  of  the  body  of 
the  uterus  remains  nearly  as  usual,  or  participates  but  little 
in  the  change. 

In  many  cases  where  the  uterus  is  apparently  prolapsed, 
the  OS  uteri  being  very  low  down,  this  does  not  proceed 
from  prolapsus  of  the  whole  organ,  but  from  the  presence 
of  hypertrophy  and  elongation  of  the  cervix  alone,  of  that 
part  of  the  cervix  which  is  above  the  vagina.  The  sound, 
when  used  under  these  circumstances,  is  a  most  valuable 
me^ms  of  diagnosis.  In  prolapsus  constituted  by  hyper- 
trophic elongation  of  the  cervix,  the  sound  can  be  made  to 
]iass  upward  for  a  much  greater  distance  than  usual.  Sir 
James  Simpson  mentions  cases  in  which  it  passed  inward  to 
a  depth  of  four  or  five  inches;  and  Muguier,  whose  observa- 
tions are  more  recent  and  extensive,  in  an  average  of  a 
large  number  of  nses,  found  the  length  of  the  uterine 
canal  to  be  4J  inch  s;  in  extreme  cases,  a  length  of  9  inches 
was  attained.  In  cases  which  I  have  examined,  with  the 
object  of  testing  riuguier's  statements,  I  have  found  the 
length  of  the  ute»  me  canal  to  amount  to  as  much  as  G\  and 
7  inches.  There  is  a  fallacy  connected  with  the  use  of  the 
sound  in  these  cases,  with  which  it  is  well  to  be  acquainted 
in  order  that  an  erroneous  inference  may  not  be  drawn. 
The  sound  is  sometimes  arrested  two  inches  or  so  from  the 
OS  uteri,  by  the  curve  which  the  lengthened  cervix  uteri 
makes  at  this  point,  and  in  one  instance  I  found  it  neces- 
sary to  pass  the  finger  into  the  rectum,  when,  by  pressing 
against  the  convexity  of  the  curve  in  question,  the  sound 
readily  passed  inward  between  two  and  three  inches 
further.  We  have  two  categories:  [a]  those  in  which  the 
(•(V-rvV^/ cavity  is  lengthened  and  at  the  same  time  pro- 
lapsed; and  {b)  those  in  which  the  uterine  and  the  cervical 
cavity  are  both  lengthened,  the  os  uteri  remaining  at  or  about 


80  DISEASES   OF  WOMEN. 

its  usual  place,  at  the  summit  of  the  vaginal  canal,  or  not 
remaining  in  this  position.  I  have  seen  a  case  in  which 
tumor  of  both  ovaries  was  present,  the  upper  part  of  the 
uterus  was  dragged  up,  and  at  the  same  time  the  lower 
part  was  pushed  downward.  The  canal  of  the  uterus  had 
an  excessive  length.     (See  Prolapsus.) 

Fibroid  Tutiiors  of  the  litems  frequently  occasion  a  con- 
siderable increase  in  the  size  of  the  cavity  of  the  organ — a 
circumstance  rendered  evident  by  the  use  of  the  sound. 
The  size  of  the  tumor  may,  however,  be  considerable,  and 
the  size  of  the  uterine  cavit)^  remain  unaffected.  The  in- 
crease in  the  length  of  the  uterine  cavity  due  to  the  pres- 
ence of  fibroid  tumor  may  reach  to  such  an  extent  that  the 
sound  passes  in  to  a  depth  of  6,  7,  or  8  inches,  a  possible 
fallacy  Sir  J.  Simpson  calls  attention  to  in  connection  with 
this  subject.  In  long-standing  cases  it  sometimes  happens 
that  the  pressure  produced  by  large  fibroid  tumors  occa- 
sions the  opposite  sides  of  the  uterine  cavity  to  adhere,  and 
the  sound  is  arrested  some  distance  below  the  real  position 
of  the  fundus  uteri. 

The  diagnosis  between  lengthening  of  the  cavity  caused 
,  by  dragging  of  the  fundus  of  the  uterus  upward,  and  that 
caused  by  the  presence  of  fibroid  tumor  in  the  walls  of  the 
uterus,  turns  on  the  relation  which  is  found  between  the 
sound  while  in  the  uterus,  and  the  tumor  occupying  the 
pelvis  and  projecting  upward  in  the  hypogastric  region. 
As  a  general  rule,  when  an  ovarian  tumor  is  dragging  the 
fundus  uteri  upward,  and  thereby  lengthening  its  cavity, 
the  sound  is  found  to  be  anterior  to  the  tumor.  To  this 
rule  there  may  be  occasional  exceptions;  and  when  the 
tumor  is  situated  laterally  in  reference  to  the  sound,  this 
means  of  distinguishing  between  the  two  is  not  available. 
When  the  tumor  dragging  up  the  uterus  is  extra-uterine, 
one  side  and  corner  of  the  uterus  is  generally  more  drawn 
up  than  the  other:  this  gives  the  course  of  the  sound  up- 
ward a  certain  obliquity,  often  characteristic. 

Fibroid  Polypus  of  the  Uterus. — When  the  polypus  remains 
within  the  cavity  of  the  uterus,  the  length  to  which  the 
sound  can  be  introduced  is  increased  in  proportion  to  the 
size  of  the  polypus.  By  means  of  the  sound,  a  very  perfect 
idea  can  sometimes  be  obtained  of  the  relations  and  place  of 
attachment  of  the  polypus,  for  the  point  of  the  instrument 
can  be  made  to  travel  round  the  included  mass  between 
•t  find  the  uterine  walls.     Q^\'^  must  be  cxerci^^d  not  to 


EXAMIXATION    OF  THE    UTERUS  AND   OVARIES.      8l 

fall  into  the  error  of  taking  the  pedicle  of  the  polypus  for 
t'.ie  summit  of  the  uterus;  it  is  possible  for  the  point  of  the 
sound  to  be  arrested  at  this  point  when  first  introduced. 

Hypertrophy  of  the  Uterus. — The  increased  length  of  the 
uterine  cavity  may  be  due  to  hypertrophy  of  the  organ,  a 
condition  wliich  is  now  and  then  found  to  be  present,  unas- 
sociated  witli  any  of  the  conditions  causing  lengthening  of 
the  cavity  hitherto  described.  The  lengthening  which  oc- 
curs in  connection  with  this  condition  is  never  very  consicl- 
erable  in  amount,  the  measurement  not  generally  exceed- 
i"&  3i  to  Z\  inches.  This  hypertrophy  and  consequent 
lengthening  (jf  the  canal  maybe  due  to  long-continued  con- 
gestive hypertrophy  of  the  uterus,  repeated  miscarriages, 
or  to  defective  involution  persisting  for  a  long  time  after 
delivery. 

In  cancer  of  the  funJus  of  the  uterus,  the  organ  might  be 
found  unduly  lengthened,  without  marked  evidence  of  dis- 
ease of  the  same  kind  at  the  cervix.  In  the  very  rare  dis- 
ease, tubercle  of  the  uterus,  elongation  and  increase  in  the 
size  of  the  organ  have  been  observed  to  be  present. 

Lastly,  in  cases  of  undue  patency  of  the  Fallopian  tube,  the 
sound  may  pass  to  an  unusual  length.  It  is  always  neces- 
sary to  examine  carefully  into  the  previous  history  of  the 
patient,  and  to  compare  the  results  of  examination  by  the 
sound  with  those  derived  from  examination  of  the  hypo- 
gastric region  of  the  abdomen,  and  it  is  advisable  to  come 
to  no  conclusion  until  a  combined  examination  by  the 
sound  internally,  and  by  the  hand  placed  over  the  hypogas- 
trium,  has  been  performed. 

THE    UTERINE    C.WAL    IS    SHORTER    THAN'    USUAL. 

When  the  depth  to  which  the  sound  can  be  introduced  ir. 
less  than  usual,  this  may  proceed,  following  Sir  James  V. 
Simpson's  classification,  from  one  of  the  following  causes: 

Preternatural  Shortness  of  the  Organ  generally,  a  congenital 
Condition. — This  congenital  shortness  of  the  canal  is  met 
with  where  the  uterus  is  imperfect!)*  developed,  the  whole 
organ  being  smaller  than  usual,  or  in  cases  in  which  the 
organ  is  unequally  developed  on  the  two  sides.  The  con- 
dition of  the  external  generative  organs  may  be  apparently 
quite  normal,  and  the  sexual  instinct  present  to  the  usual 
degree,  and  yet  there  may  be  imperfect  or  defective  devel- 
opment of  the  uterus  itself.     The  uterus  may  be  double,  or 


S2  DISEASES   OF   WOMEN. 

one  side  only  may  be  developed,  or  one  side  may  be  devel- 
oped to  a  certain  degree,  and  on  the  other  side  may  be  found 
a  less  fully  developed  cornu.  These  conditions  are  not  fre- 
quently met  with  in  practice,*  but  the  possibility  of  their 
occurrence  must  be  kept  in  view,  or  the  results  of  examina- 
tion by  the  sound  might  prove  embarrassing. 

Stricture  of  the  Uterine  Canal  or  Partial  Ol'litcration  due  to 
Pressure  of  Tumors,  etc. — The  apparent  shortening  of  the 
canal  due  to  stricture  has  been  already  alluded  to  in  speaking 
of  the  difficulties  attending  the  introduction  of  the  sound. 
In  old  people  the  internal  os  uteri,  which  is  the  point  at 
which  the  stricture,  when  present,  usually  exists,  is  often 
obliterated  (Mayer,  Matthews  Duncan).  The  cavity  of  the 
uterus  proper — that  is  to  say,  the  portion  above  the  inter- 
nal OS  uteri — may  also  be  obliterated,  and  the  sound  is  then 
arrested  at  the  same  point.  When  the  canal  is  obliterated 
hy  pressure,  as  by  large  fibroid  tumors  growing  in  the  walls 
of  the  uterus,  shortening  of  the  canal  may  be  a  consequence. 

Partial  Inversion  of  the  Uterus. — The  shortening  due  to 
partial  inversion  could  not  possibly  be  mistaken  for  that 
due  either  to  stricture  or  imperfect  development  of  the 
uterus.  In  partial  inversion,  there  is  a  tumor  projecting 
from  the  os  uteri;  the  sound  passes  into  the  os  uteri  by  the 
side  of  this  tumor,  but  cannot  be  introduced  so  far  as  usual. 
Practical  experience  has  shown  that,  in  some  cases,  the  diag- 
nosis between  partial  inversion  and  polypus  of  the  uterus 
is  one  of  the  extremest  difficulty;  but  with  the  aid  of  the 
data  obtainable  by  a  careful  use  of  the  uterine  sound,  we 
may  hope  to  s^irmount  this  difficulty.  The  important  diag- 
nostic fact  is  that  the  sound  passes  inward  to  a  less  depth 
than  usual  on  all  sides  of  the  projecting  mass.  If  the  case 
be  one  of  polypus,  the  sound  passes  inward  to  the  usual  ex- 
tent, and  the  hand  over  the  hypogastric  region  discovers 
the  fundus  of  the  uterus  in  its  usual  place.  When  polypus 
is  combined  with  partial  inversion  tlie  difficulty  is  greatly  in- 
creased, and  in  such  a  case  careful  measurement  of  the  depth 
of  the  cavity,  examination  of  the  tumor  itself,  examination 
fer  rectum,  and  of  the  hypogastric  region,  must  all  be 
brought  to  bear  in  forming  a  decision. 

Atrophy  of  the  Uterus  is  in  rare  instances  observed  after 

*  For  further  information  on  this  subject  the  reader  is  referred  to  the 
work  of  Kcssmaul,  "Von  dem  Mangel,  der  VerkUmmerung  und  Verdop- 
pUing  der  Gebiirnjuiter."     WUrzburg,  185S. 


feXAMIXATlON'  OF   THE   UTERUS  AND   OVARIES.      S3 

labor;  here  also   the  cavity  of  the   uterus  is  found    to  be 
shorter  than  natural. 

Lastly,  the  caution  may  be  repeated,  that  flexion  of  the 
canal,  causing  arrestment  of  the  proj^re^s  of  the  instru- 
ment, may  be  confounded  with  actual  sliortening. 

EXAMINATION    OF  THE  OS  UTERI   BY    MEANS  OF  THE    SPECULUM. 

By  the  use  of  the  instrument  known  as  the  "speculum.  " 
we  are  able  to  obtain  ocular  evidence  of  the  condition  of 
that  part  of  the  uterus  which  projects  into  the  vagina,  ami 
of  the  orifice  or  os  uteri. 

The  speculum  should  never  be  used  without  a  previous 
digital  examination.  The  digital  examination  will  be  the 
means  of  informing  us  whetlier  the  state  of  the  parts  be 
such  as  to  render  it  unadvisable  or  impossible  to  use  this 
instrument.  Further,  a  knowledge  of  the  size,  length,  etc., 
of  the  vagina,  ascertained  by  means  of  a  digital  examination, 
is  necessary  in  order  that  the  instrument  selected  may  be 
adapted  to  the  peculiarities  of  the  case.  The  use  of  the 
speculum  is  objectionable  in  the  case  of  young  unmarried 
wtmien,  especially  in  those  in  whom  the  hymen  is  intact. 
For  purposes  of  diagnosis  the  use  of  the  instrument  can 
but  rarely  be  considered  necessary  under  sucii  circum- 
stances. In  cases  of  cancer  of  tlie  uterus  the  instrument 
should  be  used  with  great  care:  haemorrhage  of  a  serious 
character  may  be  set  up  by  careless  employment  of  the 
speculum  under  these  circumstances.  [There  is  no  such 
danger  with  the  Sims  speculum  used  properiv.] 

The  cases  in  which  tlie  speculum  is  most  commonly  used 
for  purposes  of  diagnosis  are  the  following:  Cases  of  obsti- 
nate leucorrhoca  in  which  there  is  reason  to  suspect  the 
presence  of  an  abnormal  condition  of  the  cervix  uteri  and 
of  the  glands  there  situate:  cases  of  menorrhagia,  or  re- 
curring haemorrhage,  for  the  purpose  of  ascertaining  the 
presence  or  absence  of  small  polypoid  growths  within  the 
OS  uteri,  and  which  may  be  so  small  as  not  to  be  detected 
by  digital  examination;  cases  in  which  it  is  considered 
advisable  to  examine  ocularly  the  condition  of  the  poiiio 
vaginalis  and  os  uteri,  and  tlius  of  obtaining  evidence  as  to 
the  presence  and  nature  of  ulcerations,  abrasions,  excoria- 
tions, lacerations,  etc..  of  the  parts  in  question.  It  is  em- 
ployed in  cases  in  whicli  it  is  considered  aflvisable  to  ex- 
plore the  interior  of  the  uterus  itself,  to  facilitate,  in  some 


84 


DISEASES   OF  WOMEN. 


cases,  the  use  of  the  uterine  sound,  and  it  is  essential  in  the 
performance  of  some  operations  involving  the  cervix  or  os 
uteri. 

Method  of  using  the  S  eculuni. — The  mechanical  con- 
trivances for  getting  a  view  of  the  os  uteri  are  ver)'  numer- 
ous. Simple  tubes,  tubes  slit  up  into  two  or  three  seg- 
ments, and  lastly  the  duckbill  univalve  instrument — known 
as  Marion  Sims's — have  been  successively  employed.  It  is 
needless  to  describe  these  various  instruments  in  detail. 

The   two  instruments    which    are,    in   my  opinion,    best 

Fig.  14. 


adapted  for  the  purpose  are  a  short  bivalve  instrument  (a 
modification  of  Cusco's  speculum)  and  Sims's  speculum. 

The  modified  Cusco's  speculum  I  have  used  for  some 
time,  but  the  one  I  employ  is  large  at  the  mouth,  and  very 
portable.  Messrs.  Weiss  have  improved  the  method  of 
separating  the  blades,  and  it  is  now  a  very  complete  instru- 
ment (Figs.  14  and  16).  It  has  the  advantage  of  bringing 
tlie  OS  uteri  near  to  the  ostium  vagina;,  a  most  impoitant 
point,  and  the  aperture  or  mouth  being  large  (i^  in.  by  if 
in.)  great  facilities  for  operations  are  offered.  Its  length  is 
only  four  inches.  It  is  kept  in  place  by  its  own  action  and 
requires  no  assistant. 


EXAMINATION   OF  THE   UTERUS  AND   OVARIES.      85 

In  using  this  instrument,  the  patient  should  be  placed  on 
the  side  with  the  knees  drawn  up,  and  the  hips,  a  little 
higher  than  the  thorax,  should  be  quite  at  the  edge  of  the 
examining  couch.  The  speculum,  previously  oiled  and 
warmed,  is  introduced  in  the  collapsed  shape,  and  care 
.taken  to  direct  it  backward.  The  chief  difficulty  is  at  the 
ostium  vagina;,  but  this  is  overcome  by  drawing  the  four- 
chette  a  little  back  with  the  forefinger  of  the  left  hand,  and 
inserting  the  speculum  just  at  first  a  little  obliquely  as  re- 
gards the  plane  of  the  aperture.  It  should  be  passed  as  far 
as  possible  before  screwing  the  blades  open,  and  when  the 
screw  has  been  turned  about  three  times  it  should  be  as- 
certained whether  the  os  uteri  is  in  view.  It  frequently 
happens  that  the  speculum  has  nt»w  to  be  directed  a  little 
more  backward,  in  order  that  the  os  may  be  brought  into 
view.  The  further  separation  of  the  blades  is  then  effected. 
When  the  vagina  is  very  long  and  narrow  this  speculum 
does  not  answer  quite  so  well,  but  if  the  vaginal  aperture 
be  dilatable  it  is  of  great  service,  for  in  separating  the 
blades  the  os  is  brought  down  into  view  by  a  mechanism 
which  will  be  sufficiently  obvious.  In* cases  where  the 
ostium  vaginae  is  very  narrow,  a  smaller-sized  instrument 
of  the  same  kind  would  be  required;  but  under  such  cir- 
cumstances the  use  of  the  speculum  is  not  often  necessary. 
In  withdrawing  the  instrument  it  is  best  to  allow  the  blades 
to  collapse  to  within  half  an  inch  of  each  other,  so  as  to 
prevent  the  vaginal  walls  being  caught  between  tiiem. 

The  drawing  (Fig.  14)  shows  the  position  of  the  instru- 
ment when  introduced  and  the  blades  separated  to  an  aver- 
age extent  (i|  in.).  It  will  be  observed  that  a  good  deal  of 
the  length  of  the  instrument  is  expended  on  the  vulva.  A 
great  merit  of  this  instrument  is  that  it  expands  the  vulvar 
part  of  the  canal. 

Dr.  Meadows's  speculum  made  by  Ma\'er  and  Meltzer, 
somewhat  resembles  Cusco's,  but  two  lateral  additional 
blades  are  provided  so  as  to  separate  the  vaginal  walls 
laterally.  Further,  the  distal  end  is  smaller,  so  that  it  is  a 
little  more  easy  of  introduction  than  the  one  above  de- 
scribed. 

Another  speculum  is  that  of  Dr.  Marion  Sims,  and  a 
most  valuable  one  it  is.  It  is  kept  in  two  sizes,  giving  thus 
the  advantage  oi  four  blades,  each  of  different  width.  This 
instrument  requires  the  aid  of  an  assistant.  It  is  necessary 
to  pay  particular  attention  to  the  placing  the  patient  in  a 


86 


X)ISEASES   OF   WOMENf. 


proper  position.  The  patient  must  be  placed  as  follows: 
Having  been  brought  quite  to  the  edge  of  the  couch,  which 
should  be  about  the  height  of  an  ordinary  table,  she  is  laid 
on  the  side,  and  the  knees  drawn  up  to  the  abdomen.  The 
left  arm  is  then  placed  at  full  length  behind  the  back.  This 
throws  the  chest  a  little  forward.  I  have  found  it  best  also 
to  raise  the  hips  by  means  of  a  thin  hard  pillow  or  other- 


wise. The  speculum  is  then  introduced,  care  being  taken 
to  keep  tiie  point  of  the  blade  close  to  the  posterior  wall  or 
floor  of  the  vagina.  The  larger  or  smaller  blade  is  used 
according  to  circumstances.  When  the  blade  is  ///  siiu,  the 
instrument  is  pulled  backward  in  such  manner  that  the 
floor  of  the  vagina  is  pree:sed  against  the  rectum.  Tiie 
perinaeum  is  thus  stretched,  and  at  one  and  the  same  mo- 
ment the  ostium  vaginae  and  the  vaginal  canal  are  dilated. 
The   fundus  of  the   uterus   falls  a  lilllc  forward   in  conse- 


EXAMINATION  OF  THE  UTERUS  AND  OVARIES.   87 


t^uence  of  the  position  of  the  patient,  and  air  of  course 
enters  the  vagina.  It  is  found  tliat  in  some  cases  a  perfect 
view  is  now  given  of  the  os  uteri.  In  others  the  bladder 
and  anterior  vaginal  wall  project  backward  so  as  to  impede 
the  view,  and  when  this  happens  the  uterine  sound  or  the 
finger  must  be  used  to  pusli  the  projecting  part  aside,  or, 
what  is  still  better,  a  hook  may  be  fixed  into  the  anterior 
lip  of  the  OS  and  the  uterus  gently  drawn  down.  Dr.  Sims 
uses  a  small  delicate  tenaculum  hook  for  this  purpose. 
The  one  here  figured  (Fig.  15),  and  which  I  have  been  in  the 
habit  of  using,  is  a  little  firmer  and  stronger,  and  more 
bent  back.  It  will  be  found  that  in  drawing  down  the 
uterus  it  is  necessary  simultaneously  to  draw  the  speculum 
a  little  in  the  same  direction. 

Fig.  16. 


A  self-retaining  Sims  speculum  has  been  a  good  deal  em- 
ployed in  America.  By  the  use  of  this  instrument  the  aid 
of  an  assistant  can  be  dispensed  with.  Both  Mr.  Spencer 
Wells  and  Dr.  Savage  have  also  introduced  instruments 
constructed  on  the  same  principle. 

The  view  of  the  os  and  cervix  uteri  afforded  by  the  Sims 
speculum  is  exceedingly  good.  Manipulations  on  the  parts 
in  question  are  effected  with  extreme  facility.  The  use  of 
the  hook  is  not  attended  with  any  bad  result,  but  when  the 
patient  is  straining,  as  not  unfrequenily  happens  during 
the  exhibition  of  anaesthetics,  care  is  required  not  to  lace- 
rate the  parts. 

Fig.  15  represents  the  large  blade  in  situ,  as  when  first 
introduced.     The  hook  having  been  inserted  is  drawn  down 


8S  DISEASES   OF  WOMEN. 

about  an  inch  in  the  direction  of  the  vulvar  aperture,  bring- 
ing the  OS  uteri  with  it. 

In  some  cases  tlie  bivalve  instrument  is  better  than  the 
univalve;  but  where  assistance  is  easily  procurable  the  lat- 
ter is  very  much  to  be  preferred. 

The  bivalve  instrument  (Fig.  i6 — Cusco  improved  by 
Weiss),  as  above  described,  is  so  superior  to  the  older  bi- 
valve instruments,  that  I  do  not  describe  them.  The  tubu- 
lar glass  speculum — known  as  Ferguson's  speculum — is 
also  very  inferior  to  it.  Neugebauer's  is  a  bivalve  specu- 
lum, the  two  blades  being  distinct  and  separate.  Dr. 
Barnes  ("Obstetrical  Transactions,"  vol.  xiv.  p.  309)  de- 
scribes and  delineates  an  improved  form  of  this  instrument. 

In  a  few  instances,  as  when  the  speculum  is  used  to  ex- 
plore the  condition  of  the  vesico-vaginal  septum  in  cases  of 
fistulae,  it  is  advisable  to  place  the  patient  on  her  hands 
and  knees,  so  as  to  give  the  observer  a  good  view  of  the 
roof  of  the  vagina.  The  Sims  speculum  is  the  best  to  use 
in  this  class  of  cases. 

The  bivalve  speculum  may  be  used  with  the  patient  in 
the  lithotomy  position,  but  the  other  plan  is  far  preferable. 
It  is  generally  necessary,  by  means  of  a  dossil  of  lint  held 
at  the  extremity  of  a  pair  of  long  dressing  forceps,  to  re- 
move the  secretions  with  which  the  surface  of  the  exposed 
part  is  covered,  in  order  that  the  mucous  membrane  itself 
may  be  inspected. 

APPEARANCES    AT    THE    OS   UTERI    OBSERVED    BY    THE 
SPECULUM. 

The  ^^  OS  uteri"  is  the  lower  opening  of  the  canal  of  the 
cervix.  It  is  a  round  opening,  occasionally,  however,  trans- 
verse in  shape,  bounded  by  two  "  lips,"  an  anterior  and  a  pos- 
terior; tlie  lips  are  smooth,  uniform,  and  regular,  when  the 
woman  has  had  no  children,  but  the  surface  is  more  or  less 
fissured,  the  os  uteri  being  bounded  by  less  regularly 
formed  lips  in  women  who  have  borne  children.  The  vir- 
gin OS  uteri  is,  when  normal,  uniform,  the  vaginal  portion 
regular  and  conical  in  shape;  that  of  multiparae  is  larger, 
irregular,  and  usually  softer. 

The  appearances  presented  by  the  surface  of  the  os  uteri 
it  is  particularly  important  to  bear  in  mind.  The  lips  of 
the  os  uteri — that  is  to  say,  the  surface  of  these  lips — pre- 
sent an  appearance  very  different  from  that  which  is  ob- 
served in  the  interior  of  the   os    uteri,  and   under  ordinary 


EXAMINATION    OF   THE    UTERCS   AND    OVARIES.      S9 

circumstances  the  view  obtained  by  the  specuhim  is  not 
simply  that  of  the  labia  of  the  os,  but  of  a  portion  of  the 
interior  of  the  cervix  also,  which  has  a  tendency  to  be 
opened  out  by  the  action  of  the  speculum.  The  surface  of 
the  interior  of  the  cervix  differs  greatly  in  appearance  from 
that  presented  by  the  surface  of  the  labia,  both  in  regard 
to  the  color  and  in  other  essential  particulars,  and  there  is 
an  abrupt  line  of  demarcation  always  evident  and  generally 
remarkably  so,  between  the  surface  of  the  interior  of  the 
cervix  and  that  of  the  labia  of  the  os  uteri. 

The   lining  of  the   cen'ix   uteri — the    minute  anatomy  of 

Fig.  17.* 


which  was  first  thoroughly  described  by  Dr.  Tyler  Smith 
— is  not  smooth,  but  furrowed  and  plicated  so  as  to  present 
numerous  depressions  and  elevations  (Fig.  17),  by  which 
the  amount  of  surface  is  very  largely  increased.  The  ar- 
rangement of  the  folds  or  plicae  varies  in  different  cases. 
There  are  usually  four  prominent  elevations  longitudinally 
placed,  and  four  columns  of  rugce  or  folds  of  mucous  mem- 
brane; and  lateral  transverse  branches  are  given  off  from 
these,  the  whole  thus  acquiring  a  palmated  aspect  ;  and 
between  these  different  elevations  are  seen  others  more 
minute,  the  whole  surface  thus  presents  a  cribriform  aspect. 

*  Fig.  17  is  a  magnified  representation  of  the  interior  of   the  cervix 
Uteri.     (From  Tyler  Smith.) 


90  DISEASES   OF   WOMEN. 


The  observer,  under  ordinary  circumstances,  sees  the  lower 
and  a  small  portion  only  of  the  surface  of  the  interior  of 
the  cervix. 

Contrasting  with  the  cribriform  irregular  surface  just 
described,  the  labia  of  the  os  uteri  present  a  smooth  uni- 
form mucous  surface.  The  labia  may  themselves  be  lobu- 
lated,  and  thus  irregular,  but  the  surface  itself  is  smooth 
and  uniform.  The  epithelium  covering  the  labia  is  of  the 
squamous  variety,  identical  with  that  lining  the  vagina, 
but  luiihin  the  cervix  the  epithelium  changes,  and  the  sur- 
face is  covered  by  cylindrical  epithelium.  Higher  up  with- 
in the  cervix,  and  therefore  usually  beyond  observation  by 
means  of  the  speculum,  the  epithelium  becomes  ciliated. 

The  surface  of  the  labia  of  the  os  uteri  is  covered  by  a 
somewhat  thick  layer  of  squamous  epithelium,  as  already 
remarked.  Beneath  this  epithelium  is  a  fine  basement 
membrane,  and  these  two  cover  certain  important  struc- 
tures— the  villi  ox papillcB.  These  are  long,  single,  or  bifur- 
cated, vascular  bodies,  sometimes  so  large  as  to  be  visible 
to  the  naked  eye.  They  are  rendered  evident  by  macerat- 
ing the  cervix  uteri  in  water,  when,  the  epithelial  covering 
becoming  detached,  the  villi  are  seen  forming  an  irregular 
fringe  over  the  whole  surface.  Within  the  cervix  there  are 
also  villi  of  a  somewhat  analogous  character,  but  not  bound 
down  and  hidden  by  epithelium  as  in  the  other  position, 
and  the  villi  are  three  or  four  times  larger:  they  contain  in 
both  situations  looped  blood-vessels.  The  interior  of  the 
cervix  further  differs  from  the  labia  of  the  os  uteri  in  being 
provided  with  an  enormous  number  of  mucous  crypts  capa- 
ble of  pouring  out  secretion  in  large  quantity,  whereas 
there  appears  to  an  almost  entire  absence  of  these  glandu- 
lar organs  in  the  mucous  membrane  covering  the  labia. 

Thus,  if  tb.e  whole  of  the  epithelial  covering  were  re- 
moved from  the  surface  of  the  labia  of  the  os  uteri  there 
would  be  presented  to  the  eye  a  bright  red,  somewhat  ir- 
regular, surface  constituted  by  the  free  extremities  of  the 
villi  in  question.  An  appearance  somewhat  similar  to  this 
is  normally  presented  in  the  cavity  of  the  cervix  by  the 
villi  there  situate,  but  in  the  latter  position  the  cervix  is 
more  irregular,  due  to  the  large  size  of  the  villi,  and  of  a 
deeper  red,  owing  to  their  greater  vascularity. 

EXAMINATION    OF    THE    OVARIES. 

In  a  state  of  health  it  is  not  easy  to  determine  the  outline 


SYMPTOMATOLOGY   OF  DISEASES   OF  UTERUS.       9I 

and  position  of  the  ovaries  by  means  of  the  touch,  in  con- 
sequence of  their  position.  Ordinarily  there  is  sufficient 
space  between  the  upper  part  of  t!ie  vagina  and  the  ovary 
to  prevent  the  finger  easily  touching  tlie  ovary.  In  order 
to  practice  digital  examination  of  the  ovary,  the  patient 
should  be  placed  on  the  side  with  the  knees  well  drawn  up, 
and  the  finger  passed  as  high  as  possible  in  the  vagina. 
The  point  of  the  finger  may  tiien  be  pushed  in  the  direction 
the  ovarv  is  known  to  lie  in  until  its  presence  is  made  evi- 
dent. The  resistance  of  the  tissues  is  in  a  state  of  health 
considerable,  and  much  pressure  may  be  required  to  reach 
the  surface  of  the  ovary  and  define  its  outline.  The  ovoid 
shape  of  the  ovary  and  its  size,  together  with  a  certain 
degree  of  mobility,  are  the  characteristics  to  be  sought 
for.  When  the  ovary  is  displaced  from  its  proper  position, 
or  when  it  is  enlarged,  it  is  much  more  readily  felt.  On 
the  other  hand,  when  it  is  bound  down  by  adhesions  it  may 
be  difficult  to  recognize  it. 

In  some  cases  a  double  examination  is  practicable,  the 
fingers  of  the  other  hand  being  pressed  downward  from 
above  through  the  brim  of  the  pelvis.  The  success  of  this 
manoeuvre  depends  on  the  abdominal  muscles  being  lax  and 
tliin,  and  on  the  absence  of  a  layer  of  fat  in  the  parietes  of 
the  abdomen.  In  a  few  cases,  by  means  of  the  double 
touch,  as  above  described,  the  outline  and  size  of  the  ova- 
ries can  be  very  accurately  determined. 

There  are  other  objects  liable  to  be  met  with  on  exercis- 
ing a  digital  examination.  In  cases  when  the  Fallopian 
tube  is  enlarged  or  dropsical  the  enlargement  might  be 
confounded  with  the  ovary,  or  portions  of  the  intestine 
descending  into  the  Douglas  pouch  might  possibly  simulate 
the  outline  of  the  ovary. 


CHAPTER  IV. 

Symptomatology   of  Diseases  of  the  Uterus, 

List  of  Symptoms  Observed. — Uterine  Dyskinesia,  its  Importance  and 
Frequency — Hysterical  Symptoms — Cerebral  Symptoms. 

The  method  ordinarily  pursued  in  describing  the  diseases 
of  the  female  sexual  organs  is  to  arrange  the  subjects 
under  various  heads — some  of  these  heads  representing  the 
diseases  regarded  from  a  pathological  point  of  view,  others 


92  ■   DISEASES   OF   WOMEN. 

beinf^  mereh'  names  of  symptoms.  "Inflammation  of  the 
uterus"  and  "  Leucorrhoea"  may  be  given  as  specimens  of 
this  nosology — the  first,  pathological;  the  second,  symp- 
tomatic. 

The  method  of  clinical  observation  I  have  pursued  has 
made  me  acquainted  with  certain  important  omissions  in 
regard  to  the  symptomatology  of  uterine  diseases.  I  have 
always  adopted  the  practice  of  questioning  patients  par- 
ticularly as  to  the  sensations  or  pains  or  discomforts  which 
they  experience.  These  are  found  to  constitute  some  of 
the  more  important  of  the  symptoms  presented  by  patients, 
and  when  due  care  is  taken  to  put  no  leading  questions, 
but  to  allow  the  patient  to  give  her  own  reasons  for  obtain- 
ing medical  advice,  and  in  her  own  w'ords,  very  valuable 
data  can  be  obtained — data  which  when  properly  arranged 
are  highly  instructive  and  often  capable  of  throwing  great 
light  on  the  diagnosis  of  the  case.  The  following  is  a  list 
of  svmptoms  of  all  kinds  which  may  be  observed  in  con- 
nection with  diseases  or  affections  of  the  female  sexual  or- 
gans, these  symptoms  being  placed  as  nearly  as  possible  in 
their  order  of  frequency.  This  list  of  symptoms  I  have 
on  another  occasion  made  the  basis  of  a  clinical  discussion 
of  the  subject,*  and  I  here  reproduce  it: 

Pain  (in  the  region  of  the  uterus,  or  near  it) — 

1.  Spontaneous. 

2.  Produced  by  motion  (uterine  dyskinesia). 

3.  Undue  sensitiveness  to  the  touch. 
Leucorrhoea. 

DysmenorrhcEa. 

Menorrhagia. 

Amcnorrhcea. 

If  married — Sterility,  abortions. 

Various  reflex  phenomena: 

1.  Sickness  or  nausea. 

2.  Hysteria. 

3.  Convulsions. 

4.  Cephalalgia. 

5.  Melancholia. 

Disturbance  of  functions  of  the  bladder. 
Disturbance  of  functions  of  the  rectum. 
Disturbance  of  sexual  functions  (dyspareunia). 

*  Harveian  Lectures,  "  The  Mechanical  System  of  Uterine  Pathology.  ' 
J^ongmans,  187S. 


SYMPTOMATOLOGY   OF   DISEASES    OF    UTERUS.        93 

A  noticeable  fact  in  connection  with  the  symptomatology 
of  uterine  diseases  with  which  my  observations  liave  made 
me  acquainted  is  the  remarkable  frequency  of  a  symptom 
which  lias  attracted  very  little  attention  at  the  hands  of 
writers  on  gynaecology,  but  which  is  so  frequently  present 
that  I  have  come  to  regard  it  as  very  important.  I  refer 
to  the  symptoms  standing  second  in  the  list  justenumerated 
— viz.,  pain  in  the  neigiiborhood  of  the  uterus  produced 
by  motion.  I  have  termed  it  uterine  dyski/ieia.  By  this  is 
meant  a  painful  sensation,  or  actual  pain,  or  discomfort  of 
any  kind,  and  felt  either  at  the  back  of  the  pelvis,  or  in  front, 
or  at  the  side,  but  always  produced,  or  originated,  or  ag- 
gravated by  some  movement  of  the  body  by  standing,  or 
walking,  or  stooping,  sometimes  even  by  sitting.  This 
uterine  dyskinesia  is  really  more  commonly  observed  than 
almost  any  other  symptom.  I  think  it  desirable  to  draw 
attention  thus  prominently  to  it,  not  only  on  account  of  its 
great  frequency,  but  on  account  of  the  fact  that  it  appears 
to  be  so  important  a  symptom.  Important  for  two  reasons: 
firstly,  because  patients  themselves  so  constanth'  allude  to 
it,  and  desire  to  be  relieved  of  it;  and  secondly,  because  it 
suggests  at  once  the  importance  and  preponderance,  as 
causes  of  suffering  and  discomfort,  of  distortit;)ns,  fie-xions, 
and  changes  of  position  of  the  uterus.  The  frequency  of 
the  symptom  has  led  me  to  carefully  investigate  its  source 
and  origin,  and  with  the  result  that  I  have  been  led  to  re- 
gard these  distortions  of  the  uterus  as  playing  a  part  in  the 
female  economy  second  to  no  other  in  causing  suffering, 
pain,  discomfort,  and  chronic  incapacity  for  work  and  vari- 
ous kinds  of  exertion.  Although  in  a  few  cases  the  dyski- 
nesia is  traceable  to  disease  of  the  ovary,  in  the  verj'  large 
proportion  of  cases  it  is  the  uterus  which  gives  rise  to  the 
occurrence  of  the  symptom  in  question. 

Another  symptom  in  the  above  list  is  undue  sensitiveness 
of  the  uterus  or  parts  adjacent  to  the  touch.  One  class  of 
cases  is  that  in  which  the  condition  present  is  that  termed 
by  Dr.  Gooch  the  "  irritable  uterus."  These  cases,  as  will 
be  found  fully  set  forth  in  later  chapters,  can  be  now  satis- 
factorily explained  and  shown  to  be  cases  of  acute  flexion 
of  the  uterus  accompanied  with  congestion,  the  extreme 
sensitiveness  and  tenderness  being  due  to  this  congestion 
and  distortion  of  the  organ. 

A  series  of  symptoms  often  observed  in  women  are  the 
•'hysterical   symptoms"  so  called.     In  truth  the  relation  of 


94  _  DISEASES  OF  WOMEN. 

the  nervous  s\'Stem  to  the  sexual  organs  in  women  is  one 
requiring  a  separate  and  full  consideration  if  tliere  were 
time  and  opportunity  for  it.  These  so-called  hysterical 
symptoms  are  deserving  of  a  very  attentive  inquiry  in  view 
of  the  recent  adtlitions  to  our  knowledge  of  the  diseases  of 
the  sexual  organs.  The  more  rational  and  simple  explana- 
tions which  can  now  be  given  of  various  hitherto  obscure 
symptoms  liable  to  be  observed  in  women  will  be  found  to 
extend  themselves  to  the  peculiar  nervous  manifestations 
hitherto  described  as  "  hysterical;"  and  for  my  own  part  I 
am  quite  convinced  by  the  numerous  carefully  observed 
facts  which  have  come  under  my  notice,  that  many  of  these 
hysterical  symptoms  can  no  longer  with  any  degree  of  ex- 
actness be  regarded  as  "  fanciful  "  and  intangible  and  in- 
explicable, but  that  they  will  be  found  susceptible  of  a 
simple  interpretation. 

We  may  even  go  further  than  this.  There  appear  to  be 
very  good  grounds  for  the  belief  that  some  few  at  all  events 
of  the  cases  of  "  mental  "  disease,  long  regarded  as  calling 
only  for  the  attention  of  the  alienist  physician,  are  really 
insanities  produced  by  diseases  of  the  sexual  organs,  sus- 
ceptible of  treatment  and  relief  at  the  hands  of  the  gynaecol- 
ogist. This  is  a  subject  which  has  attracted  some  attention 
in  the  United  States  at  the  hands  of  Dr.  Storer,  Dr.  Fallen, 
and  others.  Dr.  Peaslee  recently  stated  in  a  discussion  at 
a  medical  meeting  in  New  York  that  he  had  met  with,  in 
asylums  for  the  insane,  several  cases  of  women  where  the 
cause  proved  to  be  curable  ovarian  or  uterine  disease.*  In 
my  own  practice  I  have  encountered  cases  of  a  like  char- 
acter. 


CHAPTER  V. 

General  Pathology  of  the  Uterus. 

Historical  Summary. — The  Mechanical  System  of  Uterine  Pathology — 
Definition — Laceration  of  Cervix  Uteri. 

Many  important  points  in  relation  to  uterine  pathology, 
which  have  been  subjects  of  much  dispute,  are  now  in 
process  of  settlement.  At  least  it  may  be  said  that  some 
things  may  now  be  taken  for  granted  which  were  violently 

*"Amer.  Jour.  Obstet.,"  vol.  x.  pp.  206,  284. 


GENERAL  PATHOLOGY   OF   THE    UTERUS.  95 

contested  some  seven  years  ago.  The  force  of  opinion 
is  at  present  on  the  side  of  what  may  be  termeci  new  views 
of  uterine  pathology,  although  there  are  not  wanting 
authorities  who  are  still  content  to  travel  on  the  old  lines. 

It  may  be  necessary  to  recapitulate  a  little,  but  in  setting 
forth  what  appears  to  be  a  just  and  proper  representation 
of  uterine  pathology  as  it  stands  to-day,  the  main  object 
will  be  rather  to  represent  the  present,  and  to  endeavor  to 
connect  it  with  the  futnre,  than  to  go  at  any  great  length 
into  historical  reminiscences. 

It  appears  probable,  judging  from  hints  and  statements 
scattered  through  the  writings  of  the  older  physicians, 
that  the  existence  of  displacements  of  the  uterus  have 
long  been  known — not  merely  the  severe  external  displace- 
ments which  could  not  of  course  have  escaped  recognition, 
but  those  less  severe  internal  displacements  only  to  be 
recognized  by  a  skilled  observer.  But  the  fact  remains 
that  if  the  existence  of  these  internal  displacements  were 
known,  they  were  not  properly  and  sufficiently  described 
until  comparativel}'^  recent  times. 

It  is  probable  that  knowledge  in  regard  to  the  importance 
of  these  (Hs])lacements  would  have  made  greater  progress 
some  years  ago  but  for  the  fact  that  attention  was  drawn 
off  from  them  by  the  advent  of  other  pathological  novelties. 
In  the  first  place,  the  "  inflammatory"  theory  was  applied 
to  the  subject  of  uterine  diseases,  and  little  else  was  then 
thought  of  than  accounting  for  the  various  discomforts  and 
effects  which  they  produce.  In  the  next  place,  the  dis- 
covery, or  rediscovery,  of  the  speculum  played  an  important 
part  in  diverting  attention  from  the  subject  of  displace- 
ments. Attention  was  then  concentrated  on  the  appear- 
ances presented  on  inspection  of  the  os  and  that  part  of 
the  cervix  uteri  which  could  be  exposed  to  view  by  its 
means.  It  is  probable  that  in  regard  to  advancement  of 
the  pathology  of  the  uterus  the  speculum  was  as  much  a 
loss  as  a  gain.  The  novelty  of  inspecting  the  os  uteri  and 
the  work  of  classifying  the  various  appearances  there  met 
with  forthwith  occupied  almost  the  sole  attention  of  the 
gynaecologist.  Everything  wrong  in  the  feelings  of  the 
patient,  every  discomfort  and  incapacity,  were  set  down  to 
ulceration  or  inflammation  of  the  os  and  adjacent  portions 
of  the  cervix  uteri.  The  use  of  the  sight  was  thought  all 
that  was  necessary,  and  the  position,  the  shape  and  almost 
the  very  existence  ot  tie  body  of  the  uterus  was  icnoreU, 


q6  .  DISEASES   OF  WOMEN. 

or  at  a\l  events  disregarded.  The  excessive  and  too  exclu- 
sive use  of  the  speculum  after  a  time  excited  a  reaction,  but 
its  influence  is  still  apparent,  and  the  evil  effects  of  an  ex- 
clusive employment  of  tins  method  Of  observation  are  even 
now  to  be  witnessed.  [The  advocates  of  exclusive  mechani- 
cal treatment  of  uterine  displacements  sometimes  make  the 
mistake  of  not  using  the  speculum. 

I  have  seen  many  cases  that  had  been  treated  by  pessaries 
for  months  witliout  improvement,  where  there  were  eversion 
and  erosion  of  the  cervical  membrane,  and  other  inflamma- 
tory conditions  which  would  have  been  detected  if  the 
speculum  had  been  used,  and  which  were  readily  cured  by 
appropriate  treatment.  It  is  well  to  use  every  means  for 
correct  diagnosis.] 

The  too  exclusive  attention  which  the  os  and  cervix  uteri 
had  arrogated  to  themselves,  simply  because  it  was  so  easy 
to  inspect  them  by  the  eye  aided  b)^  the  speculum,  was  after 
a  time  shown  to  be  erroneous  by  the  influence  of  the  writ- 
ings of  Scanzoni,  who  first  insisted  on  the  great  importance 
of  the  bodv  of  the  uterus,  and  who  directed  inquiry  to  this 
neglected  part  of  the  organ.  At  the  same  time  the  condi- 
tion of  the  interior  of  the  canal  of  the  cervix  uteri  was  made 
the  object  of  attention  by  Tyler  Smith.  While,  however, 
"  inflammation"  of  the  various  parts  of  the  uterus  was  occu- 
pying the  attention  of  many  observers,  the  displacements 
of  the  organ  began  to  attract  notice.  At  the  very  time 
when  in  France  the  ulceration  and  inflammation  of  the  os 
uteri  were  by  many  regarded  as  of  first-rate  importance, 
Velpeau,  in  1S54,  expressed  himself  to  the  effect  that,  ac- 
cording to  his  experience,  the  majority  of  women  treated 
for  other  affections  of  tlie  uterus  have  only  displacements, 
and  tliat  nine  out  of  ten  such  patients  in  whom  the  affection 
is  diagnosticated  as  inflammations  are  affected  by  displace- 
ments. 

The  late  distinguished  professor  at  Edinburgh,  Sir  J.  Y. 
Simpson,  contributed  greatly  to  the  increase  of  knowledge 
on  the  subject  of  displacements  of  the  uterus.  The  inven- 
tion of  the  uterine  sound  rendered  the  diagnosis  of  these 
displacements  easy,  and  he  was  well  acquainted  with  the 
grave  importance  of  Lhese  lesions.  His  beneficial  influence 
in  extending  knowledge  on  this  subject  would  possibly  have 
been  greater  but  for  the  fact  that  an  instrument  he  had  in- 
vented  for  the  treatment  of  one  variety  of  displacement 


GENERAL  rATHOLOGV  OF  THE  UTERUS.     9; 

proved  to  be  dangerous  to  life  in  some  cases  where  it  was 
employed. 

It  is  difficult  to  assign  accurately  to  different  workers  in 
the  field  ttieir  proper  share  in  the  more  modern  advances 
which  have  been  made  in  regard  to  the  knowledge  of  dis- 
placements. Much  has  been  done  in  the  United  States 
much,  particularly  of  late,  in  Germany,  but  most  of  all  i  ■ 
England.  It  is  strictly  accurate  to  say  that  England  au' 
America  share  between  tiiem  the  chief  merit  :  in  Americ 
there  has  been  a  wider  reception  of  some  of  the  doctrine.'- 
originated  on  this  side  of  the  water  than  in  England  itself. 
[Our  author  claims  too  much  for  England  on  the  score  of 
priority.  The  distinguished  Professor  Hodge  of  Philadel- 
phia, the  author  of  "Hodge's  Pessary,"  and  the  no  less  dis- 
tinguished Professor  Meigs,  of  Jefferson  Medical  College, 
both  antedate  Professor  Simpson  and  his  followers  by  many 
years.  And  Dr.  J.  Marion  Sims  informs  me  iliat  Professe'r 
Hodge  was  preceded  by  Dr.  Jennings  of  Baliimore,  who 
always  accused  Hodge  of  appropriating  his  ideas  on  the 
mechanical  treatment  of  displacements  of  the  uterus.] 

In  the  last  edition  of  this  work,  published  in  1S72,  I  en- 
deavored to  bring  more  precisely  to  a  focus  the  conclusions 
which  my  own  reading  and  careful  observation  had  induced 
me  to  arrive  at,  and  the  exposition  of  the  "  Mechanical  Sys- 
tem of  Uterine  Pathology"  therein  contained  was  the  result 
of  this  attempt. 

The  conclusion  to  which  I  had  arrived  in  substance 
amounted  to  this,  that  the  large  majority  of  the  discom- 
forts, pains,  and  inconveniences  complained  of  by  patients 
and  referred  to  the  generative  organs,  can  be  traced  to,  and 
shown  to  be  dependent  upon;  the  presence  of  mechanical 
changes  in  the  uterus,  and  to  the  effects  of  such  mechanical 
changes.  The  distortions  of  the  uterus,  together  with  the 
displacements  of  the  organ,  more  or  less  associated,  are 
thus  made  responsible  for  such  pains  and  discomforts  and 
various  other  symptoms  as  make  up,  when  put  together, 
the  greater  part  of  the  affections  of  the  generative  organs 
in  women. 

The  conclusions  seemed  at  first  of  so  sweeping  and  gen- 
eral a  character  that  I  hesitated  for  some  time  to  believe  that 
such  simplicity  belonged  to  a  subject  which  had  always  ap- 
peared so  difficult;  but  as  time  went  on,  it  was  plain  that 
there  could  be  no  mistake  about  it,  and  the  more  I  saw,  the 


9§  DISEASES   OF   WOMlEN; 

more  exactly  and  truly  did  the  principles  in  question  seem 
to  apply  themselves  naturally  to  observed  fresh  facts. 

These  conclusions  were  embodied  in  the  three  following 
propositions: 

"  I.  Patients  suffering  from  symptoms  referable  to  the 
uterus  are  almost  universally  found  to  be  affected  with  flex- 
ion or  alteration  in  the  shape  of  the  uterus  easily  recog- 
nized, but  varying  in  degree. 

"2.  The  change  in  the  form  and  shape  of  the  uterus  is 
frequently  brought  about  in  consequence  of  the  tissues  of 
the  uterus  being  previously  in  a  state  of  unusual  softness 
[or  what  may  be  often  correctly  designated  as  chronic  in- 
flammation.] 

"3.  The  flexion  once  produced  is  not  only  liable  to  per- 
petuate itself,  so  to  speak,  but  continues  to  act  incessantly 
as  the  cause  of  the  chronic  inflammation  present."* 

Since  that  time  nothing  has  occurred  to  shake  my  confi- 
dence in  the  substantial  truth  of  the  conclusions  just  stated; 
I  have  had,  on  the  contrary,  more  reason  than  ever  to  be 
satisfied  of  their  accuracy.  The  part  enclosed  in  brackets, 
and  which  refers  to  "  inflammation"  alone,  requires  to  be  al- 
tered, as  I  have  now  a  more  complete  and  satisfactory  ex- 
planation to  give  of  that  condition  alluded  to  as  "  softness." 

There  has  been  much  misconception  in  reference  to  the 
word  "  mechanical,"  as  used  in  the  phrase  "mechanical  sys- 
tem of  uterine  pathology" — a  misconception  which  it  is  neces- 
sary that  I  should  at  once  deal  with.  The  word  mechani- 
cal is  here  employed  to  convey  an  idea  as  to  the  origin  and 
nature  of  the  disorder.  B)^  it  is  intended  to  be  conveyed 
the  importance  of  the  share  which  acquired  distortions  and 
alterations  of  pobition  of  the  uterus — in  a  word,  mechanical 
changes — have  in  the  production  of  uterine  suffering.  The 
word  mechanical  has,  however,  apparently  led  some  who 
have  criticised  the  doctrines  which  I  have  upheld,  to  im- 
agine, quite  unjustifiably,  as  I  shall  b}'  and  by  show,  that  it 
has  been  my  intention  and  desire  to  inaugurate  the  uni- 
versal and  indiscriminate  employment  of  instruments  and 
mechanical  appliances  in  the  treatment  of  uterine  disease. 
Nothing  can  be  farther  from  my  object. 

The  principal  argument  employed  by  those  who  .^^'ill  re- 
sist the  idea  of  accepting  the  mechanical  system  of  uterine 
pathology  is  that,  admitting  the   frequency  with  which  al- 

*  See  Third  Edition  of  this  work,  p.  2.     Longmans,  1872. 


GENERAL  PATHOLOGY  OF  THE  UTERUS.     99 

terations  of  the  shape  of  the  uterus  occur,  these  alterations 
are  never  of  any  consequence  unless  associated  with  "  chronic 
inP.ammation,"  or,  as  some  prefer  to  term  it,  "  congestion,"  of 
the  uterus.  They  affirm  that  the  patient  suffers  not  from 
the  fle.xion,  but  from  certain  accompanying  conditions,  and 
go  even  so  far  as  to  say  that  fle.xion  by  itself  produces  no 
synptoms. 

The  whole  question  will  be  discussed  later  on;  here,  how- 
ever, it  may  be  mentioned  that  the  point  really  in  dispute  is 
tiic  connection  which  exists  between  the  flexion  and  the 
other  condition  (termed  variously  chronic  inflammation,  con- 
gestion, etc.).  There  is  no  dispute  as  to  the  importance 
of  this  "  other  cou'lition."  (In  the  three  propositions  above 
quoted,  reference  is  specially  made  to  it.)  It  is  incumbent 
on  those  who  controvert  the  mechanical  theory  to  explain 
h  >w  and  why  it  is  that  the  uterus  becomes  affected  with 
this  "other  condition,"  which  they  consider,  and,  from  one 
point  of  view  justly  so,  as  so  potent  in  producing  suffering. 
No  attempt  has  been  made,  so  far  as  I  am  aware,  to  give 
this  explanation.  The  only  substantial  criticism  which  has 
been  made  is  to  the  effect  that  patients  are  relieved  by  treat- 
ing the  congestion  alone,  the  (listortion  of  the  uterus  being 
allowed  to  take  its  course.  That  relief  to  a  certain  extent 
is  thus  obtained  is  no  doubt  true.  But  this  is  no  answer  to 
the  statement,  demonstrable  by  clinical  facts  unlimited  in 
number,  that  flexions  are  indubitably  the  principal  cause  of 
the  congestion.  Indeed,  the  congestion  may  often  be  at 
once  removed  by  restoring  tiie  uterus  to  its  proper  shape. 
These  subjects  will  of  course  be  fully  discussed  later  on. 

The  question  as  to  the  nature  of  this  "other  condition" 
so  liable  to  be  associated  with  flexions  is  of  the  greatest 
interest.  It  is  one  v.hich  has  occupied  my  attention  very 
particularlv,  and  an  intelligible  account  of  it  can,  I  think, 
be  now  given.     In  substance  the  explanation  is: 

1.  The  uterus  is  very  liable  to  fall  into  a  state  of  passive 
congestion  when  it  has  become  distorted  and  bent  upon  it- 
self, though  it  may  become  congested  from  other  causes. 

2.  The  uterus  is  very  much  more  liable  to  become  dis- 
torted when  its  tissues  are  in  a  soft,  flaccid  condition. 

3.  Softness  and  flaccidity  of  the  uterus  generally  indicate 
malnutrition  of  the  organ. 

4.  The  so-called  chronic  "inflammation"  is  generally 
chronic  congestion,  the  result  of  flexion  of  the  uterus. 

Attention  has  been  latelv  attracted  in  the  United  States 


loo  DISEASES   OF  WOMEN. 

to  the  effects  of  laceration  of  the  cervix  uteri  during  labor  as  a 
fertile  source  of  various  discomforts  and  serious  changes  in 
the  uterus.  Dr.  Emmet,  it  appears,  first  practiced  an  oper- 
ation for  the  relief  of  this  condition  in  1862,  and  he  pub- 
lished a  paper  on  the  subject  in  1874.  Dr.  Emmet  gives  a 
full  account  of  his  researches  and  numerous  operations  for 
its  relief  in  his  lately  published  large  treatise.  He  states 
that  Roser  first  described  an  ectropium  of  the  cervix  result- 
ing from  laceration.  Dr.  Emmet  attaches  very  great  im- 
portance to  this  lesion,  and  is  of  opinion  that  many  of  tlic 
recorded  so-called  cases  of  "  ulceration"  of  the  os  uteri  were 
really  cases  of  this  kind.  There  is  no  doubt  that  the  sub- 
ject is  one  deserving  of  careful  and  close  attention.  This 
lesion  has  been  curiously  overlooked,  and  much  benefit  will 
accrue  from  a  fuller  acquaintance  with  its  nature  and  treat- 
ment. A  more  particular  account  of  this  subject  will  be 
found  in  a  later  chapter  of  this  work. 


CHAPTER  VI. 


Abnorisial  Conditions  of  the  Tissues  of  the  Uterus — 
Malnutrition  of  the  Uterus — Abnormal  Softness. 

Malnutrition  of  the  Uterus  or  Abnormal  Softness.— Its  true  Pa- 
thological Nature — Evidence  of  Existence  of  General  Malnutrition  in 
such  Cases — Effects  in  Predisposing  to,  or  Causing  Distortions  of,  the. 
Uterus — Symptoms  observed — Typical  Cases. 

Under  the  older  nomenclature  the  terms  "congestion"  and 
"inflammation"  were  those  mostly  employed  in  describing 
changes  in  the  uterus  of  a  pathological  character.  These 
terms  are  no  longer  equally  appropriate.  "Congestion"  of 
the  uterus  is  a  term  which  can  still  be  employed,  but  "  in- 
flammation of  the  uterus"  cannot  be  longer  considered  as  an 
appropriate  designation. 

There  are  two  conditions  which  appear  to  stand  out  prom- 
inently as  subjects  for  particular  discussion:  (i)  A  condi- 
tion of  "  undue  softness"  of  the  uterine  tissues.  (2)  That 
condition  of  the  tissues  for  which  the  term  "congestion"  is 
still  appropriate.  It  seems  proper  to  describe  under  these 
two  heads  the  principal  pathological  changes  in  the  uterine 
tissues. 


THE  TISSUES   OF  THE   UTERUS.  101 


ABNORMAL  SOFTNESS   OF    THE    UTERUS. 

One  of  the  results  of  long'continued  observation  of  dis- 
eases of  the  uterus  has  been  to  make  me  acquainted  wiih 
tlie  fact  that  the  uterus  is  frequently  found  in  a  condition 
of  abnormal  softness.  This  softness  affects  the  tissues  of 
the  uterus  universally.  It  is  met  with  in  various  degrees  of 
intensity  in  different  cases.  It  is  to  be  recognized  by  the 
touch.  On  digital  examination  in  the  ordinary  manner  it 
is  found  that  the  tissues  of  the  os  and  cervix  uteri  have  lost 
their  natural  healthy  firm  feel,  and  this  alteration  is  usually 
traceable  upward  as  far  as  the  finger  extends.  The  softness 
is  sometimes  so  intense  that  the  outline  of  the  os  uteri  is 
difficult  to  recognize.  The  tissues  of  the  cervix  when  so 
softened  readily  allow  the  finger  to  sink  inward,  having 
lost  the  normal  firm  resistant  condition. 

It  is  well  known  that  during  pregnancy  the  tissues  of  the 
OS  uteri  become  softened,  and  the  softening,  which  can  be 
readily  recognized  in  women  two  or  three  months  pregnant, 
becomes  progressively  intensified  as  pregnancy  advances. 

The  softness  of  the  os  uteri  now  under  discussion  is  not 
dependent  on  the  presence  of  pregnancy,  though  pin'sically 
there  may  be  little  to  distinguish  between  tlie  softness  due 
to  pregnancy  and  that  observed  in  other  cases.  It  is  my 
object  to  point  out  that  extreme  degrees  of  softness  may  be 
observed  in  cases  where  no  pregnancy  exists. 

Abnormal  Softness  of  the  A^iilUparous  t/terus. — Typically,  the 
unusual  softness  now  alluded  to  is  met  with  in  young 
women  who  are  the  subjects  of  great  constitutional  weakness, 
or  who  have  been  subjected  to  the  influence  of  long-con- 
tinued insufficiency  of  food.  It  may  be  encountered  also 
in  women  who  are  married,  or  indeed  in  women  who  have 
had  children,  but  for  the  purposes  of  analysis  it  is  conveni- 
ent to  limit  the  consideration  for  the  moment  to  softening 
of  the  uterus  observed  in  young  women,  and  apart  from  the 
influence  or  consequences  of  pregnancy. 

In  the  typical  uncomplicated  cases  there  is  no  consider- 
able increase  in  the  bulk  of  the  uterus;  the  organ  is  not 
necessarily  enlarged  thereby.  The  soft  uterus  is  very  liable 
to  become  swollen  and  therefore  increased  in  size;  but  it  is 
necessary  carefully  to  separate  the  two  conditions:  (i)  Sim- 
ple softness;  (2)  Softness ////j'  congestion. 

The  softness  has  long  been  familiar  to  me  as  a  fact,  and  I 
was  for  I.  long  time  unable  to  account  for  it  or  to  give  a  sat- 


105  DISEASES  OF  WOMEN. 

isfactory  explanation  of  it.  In  the  valuable  work  by  Scan- 
zoni,  "  Die  Clironische  Metritis,"  this  autlior  forcibly  dilates 
upon  the  circumstance  that  the  so-called  chronic  intlanima- 
tory  changes  in  the  uterus  should  be  more  correctly  lo<.ked 
upon  as  chronic  nutrition-disturbances.  This  remark  was 
the  hint  to  which  I  am  indebted,  I  believe,  for  the  explana- 
tion I  have  been  since  led  to  give  of  this  abnormal  softness 
of  the  uterus;  for  an  extended  observation  of  cases  soon  led 
me  to  the  conclusion  that  this  softness  was  so  frequently 
associated  with  deficient  nutritional  activity  of  the  body  gen- 
erally, that  there  could  be  little  doubt  that  it  was  really  an 
effect  of  such  deficient  nutrition;  and  the  conclusion  1  was 
thus  led  to  form  was  to  the  effect  that  this  abnormal  softness 
of  the  uterus  observed  in  young  women  suffering  from  uter- 
ine symptoms  was  an  evidence  of  the  presence  of  malnutri- 
tion of  the  uterus. 

This  abnormal  softness  appears  to  be  the  result  of  what 
may  be  termed  "  chronic  starvation,"  and  the  essence  of  it 
to  be  malnutrition  of  the  uterus.  Tlie  age  of  puberty  is  one 
of  great  growth  and  development.  Much  nutritive  material  is 
required  to  build  up  the  frame  and  to  provide  for  the  great 
increase  in  bulk  and  in  weight  which  the  transition  from  the 
condition  of  the  girl  to  that  of  the  woman  involves.  The 
patients  who  present  this  softness  and  atonic  condition  of 
the  uterus  are  almost  invariably,  according  to  my  experi- 
ence, to  be  convicted  of  non-observance  of  the  laws  of  sup- 
ply and  demand.  They  are  found  to  have  either  taken  too 
little  nourishing  food,  or  to  have  largely  and  profusely  ex- 
pended their  vital  forces  at  this  critical  age,  or  to  have  erred 
in  both  particulars.  From  fourteen  to  seventeen  3-ears  of  age 
seems  to  be  the  time  during  which,  for  the  most  part,  mis- 
chief is  done  in  this  way,  and  it  is  fortunate  if  errors  of  this 
kind  do  not  leave  their  mark  on  the  individual  for  the  re- 
mainder of  life. 

The  above  are  generalizations  on  the  subject  which  have 
taken  long  to  mature,  and  which  are  based  on  very  numer- 
ous observations,  including  careful  inquiry  into  the  previous 
history,  the  mode  of  bringing  up,  and  the  various  possible 
predisposing  circumstances,  of  many  patients  who  have 
been  found  to  be  affected  with  this  nutritional  disorder  of 
the  uterus. 

This  softness  of  the  cervix  of  the  uterus  is  recognizable  by 
the  touch.  But  the  tissues  of  the  body  of  the  uterus  are  not 
open  to  investigation  in  the  same  way  as  those  of  the  os 


THE  tiSSUES   OF   THE    l-fERUS.  10^ 

and  cervix.  Vet  the  clinical  eviilence  adducible  shows  that 
the  softness  in  such  cases  extends  to  the  bodyof  the  uterus. 
This  evidence  consists  in  the  fact  that  in  these  cases  tlie 
uterus  is  found  to  possess  a  very  abnormal  degree  of  pli- 
ability. Tlie  softness  is  associated  in  fact  with  evidence  of 
this  abnormal  pliability  in  the  presence  of  flexions,  or  it  is 
found  by  actual  experiment  that  the  organ  does  possess  a 
very  undue  degree  of  pliability.  This  lias  a  most  impor- 
tant relation  to  the  etiology  of  flexions,  as  will  be  pointed  out 
later  on. 

In  the  worst  cases  that  have  come  under  my  notice,  the 
general  health  was  almost  invariably  in  a  very  weakened 
state.  The  patient  had  for  a  lengthened  period  eaten  very 
little.  The  condition  of  the  muscles  generally,  the  absence 
of  fat,  the  great  languor,  general  debility,  want  of  appetite, 
and  other  not  less  significant  symptoms,  showed  that  these 
patients  were  suffering  from  chronic  starvation  and  that  the 
tissues  of  the  uterus  were  thereby  weakened  in  common  with 
tliose  of  the  other  organs  of  the  body. 

The  weakening  influences  of  an  in'-ufficient  dietary  show 
themselves  in  different  ways  in  different  cases.  The  result- 
ing atrophy  and  weakness  usually,  however,  affect  more  de- 
cidedly one  organ  in  particular — in  one  case  the  lungs,  in 
another  the  brain,  and  sometimes,  as  in  the  cases  above 
described,  the  uterus. 

The  imperfectly  nourished  uterus  is,  I  believe,  always  un- 
duly soft.  The  softness  is  probably  in  great  part  due  to 
actual  deficiency  of  the  muscular  element  in  the  tissues,  but 
it  may  be  partly  due  to  defective  nerve  action,  to  impair- 
ment of  the  vaso-motor  apparatus.  There  is  a  condition  of 
the  uterus  to  which  it  may  be  desirable  to  call  attention  in 
this  place  as  bearing  on  the  question  as  to  the  cause  of  the 
softness.  When  the  uterus  is  gravid  the  tissues  of  the  os 
and  cervix  during  the  early  months  of  pregnancy  possess  a 
certain  firmness  and  resistance,  but  if  abortion  occurs,  as 
the  process  of  evacuation  of  the  contents  of  the  uterus  goes 
on,  the  lips  of  the  os  arc  observed  to  become  very  soft  and 
lax  to  the  touch.  In  fact  the  process  of  dilatation  of  the  cer- 
vix— a  part  of  the  process  of  abortion — appears  to  be  con- 
nected with  a  loosening  and  softening  of  tlie  tissues  of  the 
cervix.  There  is  of  course  no  analogy  between  the  two 
conditions:  there  is  only  a  resemblance  so  far  at  least  as 
the  physical  properties  appreciable  to  the  touch  are  con- 
cerned. 


t04  '    DISEASES   OF  WOMEN. 

I  am  gratified  to  find  that  so  experienced  an  observer  as 
Dr,  T.  Gaillard  Thomas  indorses  very  completely  the  state- 
ments I  have  made  as  to  the  effect  of  chronic  starvation  in 
producing  a  soft  condition  of  the  uterus.  In  the  fifth  edi- 
tion of  his  work  (1880),  Dr.  Thomas  says,  "The  form  of  the 
uterus — that  is,  its  muscular  strength  and  power  of  resist- 
ance— is  decidedly  affected  by  want  of  sufficient  nutritional 
material,  and  flexions  are  a  frequent  consequence;  as  Dr. 
Graily  Hewitt  has  ably  pointed  out  (p.  51).  ...  It  is  no 
exaggeration  to  maintain  that  the  American  woman,  except 
in  our  cities,  is  at  least  half-starved  "  (p.  51). 

As  a  matter  of  clinical  experience,  undue  softness  of  the 
uterus  is  very  frequentl)'  found  associated witJi  true  congestion 
of  the  tissues  of  the  uterus,  but  it  is  a  quite  distinct  condition 
from  the  latter.  It  is  very  frequently  also  found  associated 
wdth  flexions  of  the  uterus;  one  very  remarkable  class  of 
cases  is  that  in  which  the  uterus  readily,  in  consequence  of 
its  great  softness,  changes  from  one  form  of  flexion  to  an- 
other. These  latter  are  rare  cases  and  will  be  found  de- 
scribed in  a  later  chapter  as  "alternating  flexions." 

Undue  softness  of  the  uterus  would  perhaps  hardly  be 
considered  a  disease  in  the  ordinary  sense  of  the  word. 
And  yet  clinical  experience  would  indicate  that  it  is  a  pow- 
erful factor  in  the  production  of  disease.  As  such  it  de- 
serves careful  consideration  and  adequate  recognition. 

The  importance  of  the  condition  lies  chiefly  in  this,  that 
the  uterus  being  thereby  more  pliable  than  usual  is  apt  to 
become  altered  in  regard  to  its  shape,  and  this  alteration 
of  shape  may  become  permanent  after  the  condition  of  un- 
due softness  has  disappeared. 

Abnormal  Softness  following  Pregnancy. — The  foregoing  re- 
marks apply  for  the  most  part  to  the  nulliparous  uterus. 
Pregnancy  is  a  condition  which  may  leave  behind  it  a  de- 
gree of  softness  of  a  peculiar  character.  After  the  uterus 
has  expelled  its  contents,  it  remains  softer  than  usual  for  a 
variable  time.  During  the  process  of  involution  it  is  proba- 
ble that  its  tissues  are  softer  than  at  other  times.  When 
the  process  of  involution  is  a  protracted  one,  the  uterus 
may  be  found  larger  and  undul)'^  soft  some  time  after  the 
end  of  the  pregnancy.  Clinically  this  is  a  circumstance 
which  is  now  and  then  observed.  And  a  complex  condition, 
made  up  partly  of  imperfection  of  contraction  of  the  utei-us 
and  partly  of  undue  congestion  of  the  organ,  is  liable  to  be 
witnessed  under  such  circumstances.     Tlius  the  uterus  may 


THE   TISSUES   OF  THE   UTERUS.  10$ 

be  found  to  be  unduly  larrje  and  unduly  soft  also.  The 
facts  observed  in  cases  of  this  kind  seem  to  leave  very  little 
doubt  that  we  have  before  us  a  nutritional  weakness  as  in 
tlie  former  class  of  cases.  Here  the  disintegration  of  the 
uterus  is  slow;  its  reparation  is  slow  also,  and  apparently 
from  the  same  cause,  viz.,  a  deficient  activity  of  the  nutri- 
tion processes  in  the  uterine  tissues.  This  deficiency  of 
action  can  be  traced  very  frequently  indeed  to  the  insufli- 
ciency  of  diet  and  to  want  of  pro[)er  food. 

The  symptoms  observable  in  cases  of  undue  softness  of 
tlie  uterus  may  ne.xt  be  ct^sidered.  These  symptoms  pre- 
sent an  interesting  field  for  study.  One  of  the  most  con- 
stant of  these  symptoms  is  presence  of  pain  during  locomo- 
tion, or  a  pain  produced  by  movement  of  the  body.  There 
may  be  simply  discomfort  produced  by  movement.  This 
symptom  is  one  which  I  have  particularly  observed  in  its 
most  intense  degree  when  the  softness  is  associated,  as  it 
ver\' frequently  is,  with  flexion  of  the  uterus.  This  uterine 
dyskinesia  appears  in  these  cases  to  depend  upon  the  unnatu- 
ral flexibility  of  the  organ;  a  slight  motion  of  the  budy  gives 
rise  to  a  temporary  flexion  of  tlie  uterus,  and  this  produces 
tlie  pain.  Another  symptom  very  frequently  present  in 
cases  of  undue  softness  of  the  uterus  is  siikrifss  or  nausea. 
This  symptom  is  one  productive  of  great  misery  to  the  pa- 
tient, and  by  its  continuance  is  liable  to  lead  to  very  great 
weakening  of  the  system.  It  exists  in  all  degrees.  It  is 
worst  in  cases  where  there  is  flexion  also.  The  very  worst 
cases  I  have  seen  were  cases  where  the  uterus  was  exceed- 
ingly soft  and  the  flexion  had  been  overlooked  because  it 
was  of  a  temporary  character.  Nausea  does  not  necessarily 
prove  the  presence  of  softness  of  the  uterus,  because  it 
may  be  produced  by  flexion  without  concomitant  softness. 
The  most  insidious  form  of  this  symptom  is  that  where  the 
nausea  is  slight  in  degree  but  very  constantly  present. 
There  is  a  constant  disinclination  for  food,  though  there 
may  be  no  actual  vomiting.  The  patient  falls  into  the 
habit  consequently  of  taking  less  food  than  is  required; 
chronic  starvation  is  the  result. 

At  the  meeting  of  the  British  Medical  Association  held 
at  Manchester,  1877,  I  read  a  paper  on  "Abnormal  softness 
of  the  uterus  as  a  factor  in  the  etiology  of  uterine  distor- 
tions, and  as  a  cause  of   impairment  of  locomotion."*     In 

♦Published  in  Brit.  McJ.  Jour.,  Nov,  3,  iS"' 


I06  DISEASES   OF  WOMEN. 

that  paper  I  gave  particulars  of  twelve  typical  cases  (nulli- 
parous),  and  I  here  subjoin  a  few  of  them  as  illustrative  of 
the  history  of  such  cases  and  of  the  nature  and  course  of 
the  symptoms  observed. 

Case  I. — A  governess,  aged  20,  had,  when  she  first  con- 
sulted me,  been  ill  for  over  two  years.  The  difficulty 
in  walking,  which  had  existed  for  longer  than  this,  had 
finally  become  so  great  that  she  was  almost  paraplegic. 
There  was  great  general  feebleness.  The  amount  of  food 
taken  daily  was  exceedingly  small,  on  account  of  the  nau- 
sea the  idea  of  food  produced.  She  had,  after  struggling 
to  continue  her  avocation  as  a  teacher,  been  obliged  to 
give  up  entirely.  Menstruation  was  painful  and  scanty. 
Great  prostration  invariably  followed  any  effort.  There 
were  great  emaciation,  sleeplessness,  and  much  mental  de- 
pression. The  uterus  was  soft  to  the  touch,  entirely  want- 
ing in  that  firmness  the  healthy  uterus  possesses;  it  was  re- 
markably anteflexed.  The  treatment  adopted  was,  firstly, 
very  careful  administration  of  soup,  beef-tea,  and  small 
quantities  of  meat  at  frequent  intervals;  secondly,  mainte- 
nance absolutely  in  the  recumbent  position;  and,  thirdh',  re- 
position of  the  uterus  by  the  aid  of  the  sound,  and  continu- 
ous wearing  of  a  rather  small-sized  cradle  pessary.  In  a 
month  she  removed  to  the  country.  Five  months  later,  her 
condition  was  very  markedly  improved  for  the  better.  The 
pessary  was  continued,  and  the  "  rest"  treatment,  together 
with  the  careful  feeding,  persevered  in.  Iron  in  the  shape 
of  phosphate  was  ordered  from  the  first.  This  patient  was 
able  to  resume  her  occupation  to  a  great  degree  when  I 
next  heard  of  her  some  months  later,  and  has  been  steadily 
and  certainly  gaining  ground,  her  ultimate  complete  cure 
being  apparently  certain.  In  this  case,  the  initial  element 
was,  in  my  opinion,  imperfect  nutrition,  whereby  the  tis- 
sues of  the  uterus  were  rendered  soft,  pliable,  and  atonic. 
The  next  important  element  was  over-exertion,  whereby  the 
uterus  was  pushed  downward  and  its  shape  altered.  The 
anteflexion  became  more  and  more  decided;  the  nausea 
prevented  adequate  consumption  of  food;  and  a  third  most 
important  element  was  added,  namely,  starvation  in  a  chro- 
nic form.  [The  use  of  the  sound  to  rectify  anteflexion  is 
not  customary  with  us;  at  least  not  among  the  followers  of 
Dr.  J.  Marion  Sims.  He  has  always  taught  us  to  straighten 
up  an  anteverted  or  anteflexed  uterus  by  manipulation 
alone  (bi-manual).     He  passes   the  point  of  the  left  index 


THE  TISSUES   OF  THE   UTERUS.  10/ 

finger  to  the  anterior  vaginal  cul  de  sac,  resting  it  just 
against  the  anterior  face  of  tiie  cervix,  and  then  pushes  it 
up  between  tlie  anteverted  fundus  and  inner  face  of  the 
pubic  arch.  This  lifts  up  the  cervix  and  throws  the  fundus 
backward,  rotating  the  whole  organ  back  on  its  transverse 
axis.  Sustaining  it  immovably  there  by  the  left  index,  the 
fingers  of  tlie  riglit  hand  are  tlien  pressed  deeply  down  on 
the  abdomen  above  the  pubes,  where  tliey  feel  the  anterior 
face  of  the  uterus,  and  push  it  back  in  a  line  toward  the 
promontory  of  the  sacrum.  The  riglii  hand  then  holds  the 
fundus  back  while  the  left  index  is  quickly  changed  from  the 
anterior  to  the  posterior  portion  of  tiie  cervix,  moving  it 
posteriorly  even  as  high  as  the  os  internum,  and  lifting  it 
up  against  the  abdominal  parietes.  The  left  index  holds 
tlie  cervix  firmly  against  the  parietes, while  the  right  hand 
pushes  back  the  fundus,  and  thus  the  uterus  is  held  be- 
tween the  two  hands  and  moulded,  straightened,  and  mas- 
saged as  long  as  we  please  without  pain  or  suffering. 

The  use  of  the  sound  in  flexions,  whether  anterior  or  pos- 
terior, is  often  painful,  always  unnecessary,  and  sometimes 
positively  injurious,  and  should  be  abandoned.  The  only 
use  for  the  sound  is  as  a  probe.  The  Marion  Sims  method 
of  rectifying  retroversions  will  be  given  under  the  appro- 
priate head.] 

Case  J  I. — The  patient,  aged  19,  had  been  very  ill  for  two 
years  when  I  first  saw  her.  A  constant  liability  to  vomit- 
ing was  the  principal  symptom,  this  tendency  being  most 
marked  on  lying  down.  Four  years  ago  she  had  an  attack 
of  fever,  and  has  never  been  well  since.  She  is  extremelv 
feeble,  and  any  exertion  is  distressing.  Formerly,she  could 
walk  three  miles  a  day  easily.  The  nausea  set  in  rather 
suddenly;  it  is  now  present  two  or  three  days  in  a  week, 
nausea  or  vomiting  occurring  the  whole  day  long,  but  most 
intensely — and  this  is  a  curious  feature  in  the  case — on 
lying  down  in  bed  at  night.  Her  appetite  is  pretty  good. 
The  uterus  is  found  to  be  very  sensitive  to  the  touch  and 
softer  than  usual;  the  body  of  the  organ  is  enlarged.  There 
flid  not  appear  at  this  time  to  be  much  anteversion  present. 
The  further  observation  of  the  case  showed  that  the  uterus 
was  very  unnaturally  mobile,  and  that  it  was  subject  entire- 
ly to  the  action  of  gravity,  the  body  of  the  uterus  moving 
to  an  abnormal  degree  forward  or  backward,  according  to 
the  position  in  which  the  patient  lay.  It  was  found  most 
difficult  to  deal  with  this  element  in  the  case;  for,  while  it 


I08  DISEASES   OF   WOMEN. 

was  evident  that  steadying  the  uterus  produced  an  ameli- 
oration in  the  symptoms,  this  steadying  of  the  organ  was 
most  difficult  to  maintain,  owing  to  the  great  laxity  and 
size  of  the  vaginal  canal.  The  uterus  was  too  irritable  to 
allow  of  a  stem-pessary.  The  treatment  was  discontinued 
after  a  time,  removal  to  the  country  for  the  benefit  of  a 
change  of  air  being  necessary;  and  the  further  history  is 
not  known  to  me.  This  patient  was  treated  at  the  All 
Saints  Institution,  and  Dr.  John  Williams  also  saw  the  pa- 
tient several  times.  The  attack  of  fever  was  the  primary 
element  in  this  case;  the  uterus  was  weakened  thereby,  in 
common  with  the  body  generally.  The  tonicity  of  the 
uterus  was  destroyed,  and  the  nausea  and  vomiting  were 
occasioned  by  the  incessant  bending  of  the  uterus  backward 
and  forward  which  the  motions  of  the  body  produced. 

Case  III. — The  subject  of  this  case  was  an  American, 
about  20  years  of  age,  who  had  been,  to  use  her  own  ex- 
pression, "ill  all  her  life."  For  some  years  her  health  had 
been  such  that  she  could  not  enter  into  society  or  visit,  or 
walk  more  than  a  few  yards  without  extreme  inconven- 
ience. The  first  occasion  of  the  illness  appears  to  have  been 
dancing  during  a  catamenial  period.  Menstruation  is  now 
very  irregular,  the  interval  being  sometimes  as  much  as 
three  months.  Nausea  is  very  commonly  present.  There 
is  a  very  troublesome  leucorrhoea.  Of  late,  menstruation 
has  become  painful.  There  is  a  high  degree  of  "  nervous- 
ness," and  this  has  much  increased  of  late.  There  is 
constant  pain  in  the  back,  and  frequently  pain  in  the 
groins.  The  uterus  is  congested,  softened,  anteverted, 
and  so  low  down  in  the  pelvis  that  the  fundus  of 
the  organ  is  felt  through  the  vaginal  roof  almost  im- 
mediately on  introducing  the  finger.  The  sound  does  not 
enter  easily.  The  treatment  consisted  in  rest;  use  of  the 
sound,  by  which  the  uterus  was  gradually  elevated;  and 
constant  wearing  of  a  cradle-pessary.  After  two  months' 
treatment  the  patient  left,  and  was  found,  at  the  end  of  six 
months,  so  much  better  that  she  was  considered  to  be  prac- 
tically cured.  The  use  of  the  pessary  was  continued  in  all 
about  eight  months.  Locomotion  was  easy  and  natural, 
and  the  result  extremely  satisfactory.  In  this  case,  over- 
exertion in  dancing  at  the  menstrual  period  gave  rise  to  an- 
teversion  and  descent  of  the  uterus.  The  symptoms  were 
produced  by  this  unnatural  position  of  the  organ;  and  the 
congestion,  also  a  very  important  element  in  the  case,  ap- 


THE   TISSUES    OF   THE    UTERUS.  lOQ 

peared  to  be  kept  up  by  this  position.  Very  little  was 
done  except  to  replace  the  uterus  and  to  maintain  it  in  its 
place;  but  the  symptoms,  so  long  continued  and  intracta- 
ble, were  by  these  measures  subdued,  and  the  natural  ac- 
tivity of  body  restored. 

Case  IV. — The  patient  was  single,  aged  23.  The  illness, 
in  its  present  form,  has  lasted  six  months.  Menstruation 
was  irregular  from  the  first,  the  interval  being  occasionally 
six  months.  Latterly,  the  periods  have  been  regular;  but 
since  four  years  ago,  at  which  time  she  injured  herself  by  a 
leap,  the  periods  have  been  painful.  The  patient  is  now  un- 
able to  sit  upright,  and  she  can  only  walk  a  few  minutes 
without  suffering.  She  had  previously  been  active.  There 
is  a  constant  pain  in  the  back.  The  uterus  was  found  to 
be  soft,  congested,  and  anteflexed;  introduction  of  sound 
painful.  The  treatment  at  first  consisted  in  dorsal  decum- 
bency  and  occasional  use  of  the  sound.  Later  on,  a  cradle- 
pessary  was  used,  and  the  patient  went  to  the  country. 
Complete  restoration  to  health  was  the  result,  the  power  of 
walking  gradually  returning.  In  this  case,  the  general 
liealth  was  not  much  impaired.  The  case  was  a  well- 
marked  instance  of  displacement  of  the  uterus  occurring 
suddenly  and  rendered  chronic.  The  morbid  condition  had 
latterly  become  aggravated,  and  the  power  of  locomotion 
destroyed. 

Case  V. — In  this  case,  the  patient,  who  had  formerly  been 
able  to  walk  for  as  much  as  two  hours  at  a  time,  was  single, 
aged  27.  Catamenia  formerly  very  irregular.  Walking  is 
productive  of  great  uneasiness  and  pain;  a  bearing-down 
sensation  always  follows.  There  is  frequent  nausea  on  sit- 
ting up  the  first  thing  in  the  morning.  It  is  evident  that 
the  chief  illness  dates  from  a  period  of  three  years  ago, 
when  the  patient  injured  herself  in  drawing  a  cork  from  a 
bottle.  This  gave  great  pain  at  the  time,  which  continued 
to  be  felt  in  the  side  for  some  weeks  afterward.  There  is 
leucorrhoea,  occurring  in  the  form  of  occasional  gushes  of 
fluid,  evidently  from  the  cavity  of  the  uterus.  The  uterus 
is  half  an  inch  too  long,  anteverted;  but  the  sound  passes 
in  easily,  and  reduction  is  easy.  The  organ  is  soft  and  pli- 
able. The  general  health  is  bad;  there  is  great  feebleness. 
The  general  treatment  ordered  was  restorative;  rest  was 
enjoined,  and  the  uterus  supported  anteriorly  by  means  of 
the  cradle-pessary.  In  satisfactorily  effecting  this  latter 
object,  great  difficulty  was  experienced,  owing  to  the   ab- 


no  DISEASES    OF    WOMEN. 

normal  length  of  the  uterus.  A  certain  degree  of  improve- 
ment for  a  time  followed  such  treatment  as  I  was  able  to 
carry  out,  only  seeing  the  patient  once  at  intervals  of  a  few 
months.  The  general  nutrition  of  the  body  had  received  a 
shock,  which  was  difficult  to  withstand;  and  the  patient  has 
not  yet  recovered  from  the  extremely  feeble  condition  to 
which  she  had  been  reduced.  This  case  is  a  most  impor- 
tant one,  as  exemplifying  the  occasional  severe  form  which 
uterine  disease  may  assume.  The  general  health  had  be- 
come so  much  affected  that  little  or  no  restorative  power 
was  at  command,  w^hile  the  peculiar  mechanical  difficulties 
of  the  case  also  conspired  to  interfere  with  the  efficiency  of 
the  treatment.  [The  final  result  of  this  case  was  restoration 
of  locomotion  and  to  fairly  perfect  general  health.] 

The  subject  of  treatment  will  be  discussed  in  connection 
with  the  treatment  of  congestion  of  the  uterus. 


CHAPTER  VII. 
Congestion  of  the  Uterus  and  Congestive  Hvper- 

TROPHV. 

Peculiarities  of  the  Circulation  in  the  Uterus. — Effect  of  Com- 
pression at  the  Centre  of  the  Uterus  in  Producing  Congestion  at  its 
Two  Extremities — General  Congestion:  Causes — Acute  and  Chronic 
Varieties — Relation  of  Acute  Form  to  Gooch's  "  Irritable  Uterus" — 
Effect  of  Flexions  in  Causing  Acute  Congestion — Chronic  Conges- 
tion: Causes  and  Effects — Increase  in  Size  of  Uterus — Association  of 
Chronic  Congestion  with  Flexions. 

Congestion  of  the  uterus  implies  a  fulness  and  distension 
of  the  blood-vessels  of  the  organ,  which  may  be  slight  in 
degree  or  considerable.  The  congestion  may  be  partial, 
affecting  some  portions  of  the  organ  more  than  others,  or 
it  may  affect  the  whole  organ.  The  congestion  may  be 
temporary  and  evanescent,  or  it  may  be  continuous  and 
persistent. 

Congestion  of  the  uterus  may  also  be  simple  or  compli- 
cated. When  it  has  assumed  a  chronic  form  it  is  almost 
always  complicated,  the  tissues  of  the  uterus  becoming 
altered  in  other  w-ays  also. 

In  discussing  this  important  question  it  is  necessary  to 
direct  attention  to  the  peculiarities  of  the  circulation  of  the 
uterus;  these  peculiarities  having  a  direct  bearing  on  the 
nature  and  etiology  of  uterine  congestion, 


CONGESTION   OF  THE    UTERUS. 


I  I  I 


The  vessels  of  the  uterus  enter  for  the  most  part  along 
the  sides  of  the  organ.  The  arteries  are  derived  from  the 
uterine  artery,  which  passes  upward  from  below,  along  the 
sides  of  the  uterus,  giving  off  very  numerous  branches 
which  pass  inward  to  the  uterus,  and  the  greater  number 
of  them  about  'he  situation  of  the  internal  os  uteri.  These 
branches  of  the  uterine  artery  are  mainly  concerned  in  giv- 
ing arterial  blood  to  the  uterus,  but  not  entirely  so,  for 
there  is   a   free  inosculation    at  Fig.  i8. 

liie  junction  of  the  Fallopian 
tube  and  the  fundus  uteri,  be- 
tween the  extremity  of  the  uter- 
ine artery  and  that  branch  of 
the  spermatic  artery  wiiich  sup- 
plies the  Fallopian  tube  itself. 
Were  it  not  for  this  inoscula- 
tion, which  is  effected,  however, 
through  a  vessel  small  in  calibre, 
cutting  off  the  circulation  in  the 
uterine  arteries  would  deprive 
tlie  body  of  the  uterus  of  blood.* 
The  veins  issue  from  the  sides  of 
the  uterus,  forming  large  plex- 
uses around  the  organ.  It  fol- 
lows from  these  considerations 
that  compression  of  the  uterus 
about  its  middle,  such  as  would 
be  produced  for  instance  by  ap- 
plying a  ligature  round  it  at  that 
situation,  would,  according  to 
the  degree  of  tightness  of  the 
ligature,  obstruct  the  circulation 
in  the  part  of  the  uterus  near  the  middle,  viz.,  the  body  of 
the  uterus.  It  is  evident  also  that  if  the  constricting  liga- 
ture were  widened  so  as  to  compress  also  the  vessels  a 
little  above  and  a  little  below  the  middle  of  the  organ,  there 
would  arise  an  obstruction  to  the  circulation,  both  in  the 
body  and  in  the  cervix  of  the  uterus.  The  uterus  is  liable 
to  a  form  of  compression  which  acts  more  or  less  exactly 
as  an  artificial  compress  might  be  made  to  act,  when  it  is 
bent  upon   itself  and   thrown   into  a   state  of  flexion.     It 


; 


h 


K 


*The  arteries  of   the  uterus  ars   well  delineated  in   Plate   5   of  Dr 
Savage's  work,  2d  ed. 


112  DISEASES    OF   WOMEN. 

is  true  that  the  vessels  are  outside  of  the  uterus,  and  it 
may  be  conceded  that  the  bending  of  the  uterus  itself  may 
leave  the  main  trunks  still  patent  as  ever,  but  the  moment 
they  enter  the  tissues  of  the  organ  they  inevitably  fall 
under  the  effect  of  compression.  A  disturbance  in  the  cir- 
culation in  the  body  of  the  uterus  thus  results — a  disturb- 
ance which  the  small  anastomotic  branch  connecting  the 
spermatic  and  uterine  arteries  cannot  adequately  rectify. 

The  veins  going  from  the  fundus  uteri  to  the  ovarian 
bulb  appear  to  be  entirely  insufficient  to  relieve  congestion 
of  the  body  of  the  uterus  produced  by  impediment  to  the 
circulation  existing  at  the  centre  of  the  uterus.  Indeed  if 
the  outlet  toward  the  ovaries  were  sufficient,  congestion  of 
the  body  of  the  uterus  would  not  occur.  That  it  does  occur 
shows  the  insufficienc}'  of  the  ovarian  outlet  as  a  means  of 
emptying  the  veins  of  the  body  of  the  uterus. 

The  accompanying  drawing  (Fig.  i8,  from  Dr.  A.  Farre) 
represents  a  section  of  the  uterus,  and  exhibits  the  thickness 
of  the  uterine  walls. 

A  second  figure  (Fig.  19,  also  from  Dr.  Farre)  exhibits  a 
Pj^   jq  transverse    section    of    the 

uterus  at  the  situation  of 
the  internal  os,  and  the  sec- 
tion of  the  uterine  vessels 
as  they  lie  at  the  sides  of 
the  uterus  is  ver^'  well 
shown. 

With  these  two  figures 
before  us  it  is  easy  to  under- 
stand what  happens  when 
the  uterus  come^  to  be  acutely  bent.  The  next  drawing  (Fig. 
20)  represents  the  condition  present  in  anteflexion  of  the 
uterus,  and  the  effects  of  the  flexion  in  compressing  the  uter- 
ine tissues  at  the  concave  side  of  the  bend.  The  walls  of  the 
uterus  are  also  drawn  thicker,  and  the  dark  shading  is  in- 
tended to  show  the  congestion  which  results  in  the  whole 
of  the  upper  part  of  the  uterus  from  the  compression  of  the 
vessels,  and  also  at  the  os  uteri  and  cervix,  below  the  part 
where  the  compression  is  exercised. 

General  congestion  of  the  uterus  will  be  first  described. 
Here  the  whole  organ  is  too  full  of  blood,  and  as  one  re- 
sult it  becomes  larger  and  heavier  than  usual.     It  seems 
certain   that  a  condition  which  may  be   termed  a  normal 
general  congestion  exists  at  the  time  of  menstruation,  and 


CONGESTION   OF   THE    UTERUS. 


II 


that,  as  Rouget  first  pointed  out,  there  is  as  a  result  a  quasi- 
erection  of  the  whole  organ  at  this  period.  It  would  be 
proper  to  use  the  term  "  menstrual  congestion"  to  designate 
this  condition,  which  simply  implies  that  at  the  time  of 
menstruation  there  is  a  certain  amount  of  congestion  and 
fulness  of  the  vessels  of  the  uterus.  In  health  this  degree 
of  congestion  is  probably  slight,  but  doubtless  in  disease  it 
is  capable  of  easily  extending  itself,  so  to  speak,  and  thus  the 
congestion  may  be  extensive  both  in  degree  and  in  duration. 
General  congestion  of  the  uterus  may  arise  from  general 
im.pairment  of  tlie  circulation,  especially  such  as  produces 

Fig.  20. 


interference  with  the  abdominal  viscera.  One  of  the  com- 
monest varieties  of  it,  for  instance,  is  that  met  with  in  Eu- 
ropean women  living  in  India.  General  diseases,  of  what- 
ever kind,  capable  of  lowering  the  force  of  the  heart's  action 
may  lead  to  general  congestion  of  the  uterus;  a  loaded  con- 
dition of  the  bowels;  mechanical  pressure  of  abdominal  tu- 
mors; excessive  sexual  indulgence, — are  some  of  the  other 
more  important  determining  causes. 

General  congestion  of  the  uterus  may  be  acute  or  chronic. 
In  the  acute  form  it  is  rare  unless  associated  with  an  actual 
mechanical  disturbance  in  the  organ  itself,  as,  for  instance, 
in  cases  of  acute  retroflexion;  but  there  is  one  class  of 
cases  in  which  probably  what  may  be  termed  acute  general 
congestion  of  the  uterus  occurs,  viz.,  those  cases  in  which 
the  patient,  while  menstruating,  or  just  before,  or  just  after 
the  period,  receives  a  violent  chill  from  sitting  in  a  cold 


114 


DISEASES   OF   WOMEN. 


bath,  bathing  in  the  sea,  standing  on  a  wet  floor,  etc.,  and 
there  results  a  severe  and  general  congestion  of  the  whole 
uterus.  It  is  true  that  in  some  of  these  cases  of  sudden 
chill  or  shock  the  mischief  produced  thereby  may  not  be 
always  precisely  the  one  here  indicated.  Acute  general 
congestion  of  the  uterus,  however,  produced  in  this  way,  is 
a  very  serious  affair,  and  though  not  perhaps  always  imme- 
diately productive  of  grave  results  it  may  leave  behind 
it  a    permanent    and    troublesome    disease.      It  does    not 

Fig.  21.* 


appear  that  such  acute  attacks  are  common  except  at  or 
near  menstrual  periods. 

The  most  important  class  of  cases  of  acute  congestion  of 
the  uterus  is  that  in  which  the  uterus  is  distorted  and  its 
shape  altered,  and  there  arises  in  connection  with  this  an 
acute  congestion  of  the  uterus,  which  affects,  according  to 
circumstances,  some  parts  of  the  organ  more  than  others. 
It  is  met  with  in  association  with  retroflexion  in  its  most 
severe  form,  but  anteflexion  is  sometimes  conjoined  with 
very  acute  congestion. 

The  class  of  cases  now  alluded  to  comprises  those  which 
were  formerly  described  by  Dr.   Gooch,   under  the  term 


*  Fig.  21  represents  acute  "traumatic"  congestion  in  a  case  of  retro 
rle.xion. 


CONGESTION   OF  THE    UTERUS.  II5 

"irritable  uterus."  It  is  now  some  years  since  I  published 
a  paper  on  this  subject,  the  object  of  which  was  to  point 
out  what  I  considered  to  be  the  true  pathology  of  these 
cases.  The  subject  will  have  to  be  alluded  to  in  the  chap- 
ter on  Flexions.  Here  it  may  be  sufficient  to  say  that  acut? 
flexions  are  liable  to  be  attended  with  very  acute  congestion 
of  the  uterus.  The  organ  becomes  swollen,  hard,  exces* 
sively  tender  to  the  touch — so  much  so  that  the  patient 
cannot  bear  even  the  idea  of  an  examination  being  made. 
The  body  of  the  uterus,  which  can  be  felt  by  the  finger 
cither  in  front  or  behind  the  cervix,  according  to  the  kind  of 
llexion  present,  is  the  most  abnormally  sensitive.  The  os 
uteri  and  cervix  participate  more  or  less  in  the  congestion 
present,  and  they  may  be  found  swollen  and  enlarged  also. 
The  whole  uterus  is  of  course  in  a  state  of  the  greatest  irri- 
tation under  such  circumstances.  The  irritation  persists 
along  with  the  congestion.  The  congestion  may  be  very  pro- 
tracted if  the  condition  is  unrelieved  by  treatment,  but  it 
may  rapidly  pass  away  if  judiciously  managed.  The  phe- 
nomena observed  under  these  circumstances  convey  the 
most  valuable  information  in  regard  to  the  potency  of  flex- 
ions in  causing  congestion  of  the  uterus,  and  in  maintaining 
it.  The  contrast  offered  by  the  former  complete  want  of  suc- 
cess in  remedying  these  troublesome  cases,  and  the  present 
rapidly  successful  treatment  is  the  best  proof  that  could  be 
offered  of  the  accuracy  of  the  above  pathology.  The  con- 
gestion appears  to  be  acute  in  proportion  to  the  degree  of 
bending  which  the  uterus  undergoes.  Here  we  have  the 
application  to  make  of  our  knowledge  of  the  peculiarity  of 
the  circulation  in  the  uterus  spoken  of  at  p.  iii.  Tiie  in- 
tense swelling  of  the  body  of  the  uterus  produced  by  the 
compression  of  the  flexion  is  sometimes  so  severe  as  to  jus- 
tify the  use  of  the  term  "  strangulation  of  the  uterus,"  to 
which  I  called  attention  some  years  ago.*  It  is  quite  analo- 
gous to  the  congestion  of  the  hand  and  forearm  which  is 
produced  when  the  fillet  is  tied  round  the  arm  for  the  oper- 
ation of  venesection.  The  blood  is  detiiined  in  the  vessels, 
particularly  the  capillaries  and  veins,  and  congestion  thus 
arises.  And  it  is  the  fact  that  the  removal  of  the  com- 
pression, which  can  be  effected  more  or  less  quickly  by 
straightening  the  uterus,  has  the  effect  of  relieving  the 
congestion  in  a  manner  strikingly  speedy  and  satisfactory. 

*  Brit.  Med.  Assoc.  Meeting  at  Newcastle-on-Tyne. 


Il6  DISEASES   OF  WOMEN. 

The  fact  that  flexions  are  thus  capable  of  determining  and 
causing  severe  congestion  of  the  uterus  is  a  radical  one  in 
regard  to  its  importance:  it  is  one  which  has  been  noticed 
by  Klob:  Thomas  fully  endorses  it  in  his  edition  of  1873. 
It  will  be  found  to  have  a  wide  application  in  gynaecologi- 
cal practice.  Probably  the  best  term  to  use  to  designate 
congestion  of  the  uterus  produced  in  this  way  is  "  trauma- 
tic congestion."  Dr.  John  Williams,*  in  an  interesting  pa- 
per on  "  The  Relation  between  Congestion  of  the  Uterus 
and  Flexion  of  the  Organ,"  points  out  that  when  the  uterus 
is  retrofiexed,  the  fundus  is  liable  to  be  caught  and  con- 
stricted by  the  utero-sacral  ligaments,  and  that  under  such 
circumstances  there  would  arise  a  further  mechanical  cause 
of  congestion. 

Acute  congestion  of  the  uterus  may  produce  a  very  great 
increase  in  its  size.  Thus  in  some  cases  of  flexion  I  have 
found  the  uterus  almost  as  large  as  the  fist,  and  it  may  at- 
tain this  size  in  a  comparativeh'  short  space  of  time.  The 
following  is  a  case  of  this  kind  which  came  under  m}'  notice 
quite  recently: 

Miss ,  aet.   19,  has   always   been    weak   and   delicate. 

Of  late  she  has  been  incapable  of  walking,  and  during 
the  last  few  weeks  has  suffered  from  severe  pains  in  the 
hypogastric  region,  with  difficulty  and  frequency  of  mic- 
turition. On  examination  it  Avas  found  that  there  was 
apparently  a  large  tumor,  smooth  and  hard.  occup3-ing 
the  pelvis,  pushing  down  the  vaginal  roof  in  front  of 
the  uterus,  of  which  it  seemed  a  part.  The  size  of  this 
W'as  so  great  that  I  thought  it  was  really  a  tumor,  and 
a  more  complete  examination  under  anaesthesia  was  evi- 
dently necessary.  Meanwhile  the  patient  was  ordered 
to  lie  down  and  keep  quiet.  After  the  lapse  of  a  week 
further  examination  was  made.  It  was  then  found  that 
the  supposed  tumor  had  almost  disappeared  ;  it  had  re- 
solved itself  into  a  moderately  large  anteflexed  uterus. 
The  rest  and  recumbent  position  had  produced  this  effect. 
Any  one  making  an  examination  on  the  first  occasion  would 
have  been  entirely  unprepared  to  find  in  a  few  days  such  a 
change  in  the  size  of  the  uterus  as  undoubtedly  occurred  in 
this  case. 

Chronic  congestion  of  the  uterus  must  next  be  considered. 

In  its  first  stage  chronic  congestion  is  little  more  than  a 

*  "  Obst. Trans.,"  vol.  xvi.,  p.  203. 


CONGESTION  OF  THE   UTERUS. 


117 


slight  engorgement  of  the  uterine  vessels,  with  increase  in 
its  weight.  There  is  at  first  nothing  beyond  increase  in  the 
size  and  fulness  of  these  vessels,  without  any  particular 
molecular  change  in  the  tissues  of  the  uterus. 

When  present  in  a  slight  degree,  general  congestion  of 
the  uterus  at  first  may  produce  a  certain  degree  of  softness 
of  the  tissues  of  the  uterus,  the  organ  becoming  enlarged 
and  looser  than  usual  in  texture.  In  other  cases,  on  the 
other  hand,  it   becomes  firmer  than  ordinary.     The  dilfer- 

FiG.  22.* 


ence  seems  eo  be  explainable  by  attention  to  the  condition 
of  the  uterus  which  existed  before  the  congestion  set  in. 
Thus,  in  cases  of  undue  softness  arising  from  malnutrition 
of  the  uterus  nothing  is  more  common  than  to  find  that 
congestion  is  added  to,  or  affects  the  already  soft  uterus. 
A  large,  flabby,  unresisting  condition  of  the  uterine  tissues 
will  then  result.  But  in  the  case  of  a  uterus  in  a  state  of 
health  previously,  the  addition  of  congestion  will  produce 


*  Fig.  22  shows  congestion  and  enlargement,  with  anteversion,  in  a 
patient,  act.  i3,  affected  for  nearly  one  year  with  severe  vomiting. 


ii8 


biSEASES   OF   WOMEN\ 


a  different  effect  ;  the  tissues  of  the  organ  will  then  by  con- 
tinual congestion  be  made  harder  and  firmer  than  they 
were  before.  There  are  certainly  these  two  types  of  cases 
observable  in  practice.  Another  precedent  or  concomitant 
condition  which  may  be  taken  into  account  is  defective  in- 
volution of  the  uterus  after  delivery  or  after  abortion. 
Here  the  organ  is  large  and  heavy,  and  the  condition  is  one 

Fig.  23.* 


of  continuous  general  congestion,  because  the  vessels  are 
large  and  the  uterine  solid  constituents  of  undue  bulk. 
Defective  involution  of  the  uterus  is  thus  one  of  the  causes 
of  chronic  general  congestion  of  the  organ,  and  there  are 
good  reasons  for  the  belief  that  the  sluggish  manner  in 
which  the  uterus  involutes  itself  is  due  to  general  impair- 


*  Fig    23  shows  chronic  congestive    hypertrophy,  with  anteflexion  of 
tlie  uterus  of  many  years'  standing. 


CONGESTION   OF  THE    UTERUS.  Itg 

tlierit  of  the  nutritive  processes  in  the  body  generally,  and 
in  the  uterus  in  particular. 


CONGESTIVE    HYPERTROPHY. 

A  common  effect  of  general  chronic  congestion  of  the 
uterus  is  an  increase  of  the  solid  constituents  of  the  uterus.  At 
first  there  is  simply  undue  fulness  of  the  blood-vessels,  but 
after  a  time  there  is  addition  to  the  solid  parts.  The  addi- 
tion consists  in  increased  growth.  The  result  is,  that  the 
organ  as  a  whole  is  larger,  heavier,  and  thicker  than  before. 
The  tissues  of  the  uterus  consist  of  unstriped  muscular 
fibre  and  fibre  cells,  and  intervening  cellular  tissue.  These, 
together  with  the  vessels,  nerves,  and  lymphatics,  compose 
tlie  uterus.  In  chronic  general  congestion  the  connective 
tissue  appears  to  undergo  after  a  time  decided  increase  in 
quantity.  The  increase  in  bulk  is  in  all  jirobability  due  in 
part  also  to  the  further  growth  of  the  muscular  element, 
l)ut  the  general  impression  is  that  the  cellular  tissue  is 
most  affected.  The  uterus  becomes  after  a  time  harder 
tlian  the  normal  uterus.  It  is  thus  both  larger  and  harder 
than  before  attacked  by  chronic  congestion.  And  when  a 
section  of  it  is  made,  the  tissues  are  seen  to  be  decidedly 
hard  and  to  resist  the  knife.  This  condition  of  the  uterus 
has  been  described  as  "chronic  inflammation,"  "chronic 
metritis,"  etc.  Professor  Thomas  of  New  York  terms  it 
"areolar  hyperplasia."  Klob  describes  it  as  "continual 
hypersemia."  The  term  which  appears  to  me  most  cor- 
rectly to  define  the  condition  in  question  is  "congestive 
hypertrophy." 

The  increase  in  bulk  and  the  consequent  hardness  result- 
ing in  the  production  of  the  condition  now  described  as 
congestive  hypertrophy,  is  a  further  stage  of  gt^neral  con- 
gestion of  the  uterus. 

Chronic  congestive  hypertrophy  of  the  uterus  is  a  very 
common  affection.  It  is  not,  however,  very  common  unas- 
sociated  with  alteration  of  shape  of  the  organ.  It  is  liable 
to  h& partial,  involving  one  part  of  the  uterus  more  than 
another.  A  common  variety  of  it  is  the  uterus  distorted  by 
a  flexion  of  long  standing,  the  fundus  in  a  state  of  conges- 
tive hypertrophy,  the  lips  of  the  os  uteri  swollen  and  also 
in  a  state  of  congestive  hj'pertrophy,  but  generally  one  lip 
more  decidedly  swollen  than  the  other.  Such  a  uterus  is 
liable  to  take  on  at  any  time  z  further  congestive  action — 


120  DISEASES   OF   WOMEN. 

there  occur,  in  fact,  repeated  attacks  of  congestion,  as  it  is 
termed,  the  repetition  of  which  attacks  has  the  effect  of 
increasing  gradually  the  size  of  the  organ.  The  uterus  be- 
comes moulded  and  swells  in  the  direction  of  least  resist- 
ance, and  becomes  literally  hardened  in  its  evil  ways. 
This  is  a  common  type. 

A  really  general  congestive  hypertrophy  of  the  uterus, 
the  uterus  still  retaining  its  normal  shape,  is  not  common  ; 
but  such  a  condition  sometimes  results  from  defective  in- 
volution of  the  uterus. 

Chronic  congestive  hypertrophy  of  the  uterus  is  not  easy 
to  distinguish  from  defective  involution  of  the  uterus  after 
delivery.  Microscopically,  however,  there  would  probably 
be  a  difference,  the  muscular  element  predominating  in  the 
latter  case,  and  the  connective  tissue  element  in  the  for- 
mer. 

The  hypertrophic  condition  of  the  uterus,  as  already  re- 
marked, is  very  frequently  noted  in  cases  of  flexion  or  dis- 
tortion of  the  uterus  ;  and  by  some  authorities  (Dr. 
Thomas  of  New  York,  e.g.)  the  hypertrophy  is  looked  upon 
as  the  cause  of  the  displacement.  Undoubtedly  this  ex- 
])lanation  applies  to  that  variety  of  hypertrophy,  the  result 
of  defective  involution  after  delivery,  but  it  is  probably  not 
generally  the  case  in  other  instances. 

The  size  which  the  uterus  attains  in  cases  of  chronic  con- 
gestive hypertrophy  is  sometimes  very  great.  Thus,  I  have 
met  with  cases  of  anteflexion  in  which  the  uterus  was  so  wide 
from  side  to  side  that  it  seemed  almost  to  fill  the  anterior 
half  of  the  pelvis,  having  the  size  of  a  cricket-ball,  or  even 
larger.  Fig.  23  represents  a  case  of  long-standing  general 
hypertrophy  of  the  uterus,  associated  with  anteflexion. 
Hypertrophy,  to  an  equal  extent,  is  not  often  witnessed 
with  retroflexion. 

Chronic  hypertrophy  often  affects  the  lips  of  the  cervix 
uteri ;  the  os  uteri  is  then  surrounded  with  tissues  some-' 
times  enormously  thickened.  This  hypertrophy  of  the 
vaginal  portion  of  the  cervix  may  be  associated  with  flexion 
of  the  uterus  or  may  be  the  result  of  a  former  flexion.  Ii 
may  also  be  produced  by  laceration  of  the  cervix.  It 
seems  to  me  very  probable  that  many  of  those  cases  in 
which  the  os  uteri  presents  rounded  projecting  lips  of  con- 
siderable size  have  their  origin  in  such  laceration.  At  all 
events  it  is  certain  that  such  rounded  hypertrophy  of  the  lips 
of   the  OS  uteri  is  observed   in  cases  of  lacerated   cervix. 


SUB-INVOLUTION   OF   THE    UTERUS.  121 

The  congestive  hypertrophy  in  these  cases  appears  to  de- 
pend on  the  interference  with  tlie  circulation  in  tlie  tis- 
sues produced  by  the  laceration,  for  I  have  seen  it  rapidly 
disappear  when  the  laceration  has  been  repaired  and  the 
normal  circulation  restored. 


CHAPTER  VIII. 


Sub-involution    of    the  Utf.kus — Atrophy  and  Hvper- 

TROPHV    OK    THE    UtERUS. 

Sub-involution  of  the  Uterus. — Nature  and  Treatment. 

Atrophy  of  the  Uterus;  the  result  of  Sexual  Involution — Premature 

Senile    Atrophy    or    "Super-involution"    of    the    Uterus — Mechanical 

Atrophy. 
Hvpertrophy  of  the  Uterus. — Result  often  of  Defective  Involution 

after  Delivery — Hypertrophy,  with  Elongation  of  the  Cervix. 

SUB-INVOLUTION  OF  THE  UTERUS — NATURE  AND 
TREAT.MENT. 

The  condition  of  the  uterus  described  under  the  term 
sub-involution  has  been  already  incidentally  alluded  to. 
But  it  is  convenient  to  give  it  a  distinct  and  separate  con- 
sideration, inasmuch  as  it  is  a  factor  of  considerable  impor- 
tance in  many  cases  of  uterine  disease. 

Sub-involution  of  the  uterus  may  be  observed  after  par- 
turition at  full  term  or  following  an  abortion.  The  uterus 
does  not  return  to  its  proper  size,  but  remains  larger  than 
it  should  be.  That  is  to  say,  that  process  of  diminution  in 
bulk  which  is  natural  under  such  circumstances  is  delayed 
beyond  the  proper  time.  The  uterus  may  be  found,  for  in- 
stance, as  large  at  the  end  of  a  month  after  parturition  as  it 
should  be  at  the  end  of  a  week  from  the  time  of  labor.  The 
persistence  of  a  bulky  condition  of  the  uterus  under  these 
circumstances  means  either  that  the  metamorphosis  of  the 
large  uterine  muscular  fibres  into  fatty  material,  and  ab- 
sorption thereof,  is  delayed,  or  it  means  that  there  is  a 
delay  in  the  metamorphosis  together  with  congestion  of  the 
uterus.  It  is  probable  when  a  few  weeks  have  elapsed  and 
the  uterine  bulk  is  still  considerable,  that  the  case  is  one  of 
arrested  metamorphosis////5' considerable  congestion,  rather 
than  arrested  metaiTiorphosis  alone. 

At  first  the  uterus,  in  a  state  of  sub-involution,  may  be 
soft  and  spongy  to  the  touch,  but  later  on  it  is  not  so,  and 


122  DISEASES   OF   WOMEN. 

the  condition  is  one  rather  of  hardness  than  softness.  After 
a  time,  in  fact,  the  condition  becomes  merged  into  one  of 
congestive  hypertrophy,  or,  as  it  would  be  termed  by  Dr. 
Thomas,  "areolar  hyperplasia"  of  the  uterus. 

The  microscopic  condition  of  the  uterus  will  be  found  to 
vary  according  to  the  time  which  has  elapsed  since  parturi- 
tion or  abortion;  for  if  the  examination  be  made  early  mus- 
cular fibres  in  excess  will  be  found,  whereas  later  on  there 
will  be  a  superabundance  of  cellular  connective  tissue  ma- 
terial. 

Displacements,  especially  flexions  of  the  uterus,  are  causes 
of  sub-involution  of  the  uterus.  Thus,  I  saw  a  case  of  acute 
displacement  of  the  uterus  backward,  occurring  very  soon 
after  labor,  where  the  uterine  fundus  must  have  retained 
its  abnormal  size,  in  this  retroverted  condition,  for  manj^ 
days  after  the  displacement  occurred.  The  sub-involution 
in  this  case  was  thus  caused  by  the  displacement;  probably 
in  consequence  of  the  arrest  of  the  circulation  in  the  uterus 
thereby  produced.  I  have  seen  several  other  cases  of  some- 
what similar  character.  It  is  not,  however,  necessary  that 
the  uterus  should  be  displaced  in  order  that  sub-involution 
may  occur,  for  cases  are  encountered  where  there  has  been 
no  such  dislocation.  Of  the  other  causes  of  sub-involution 
of  the  uterus  probablj'  mal-iiiitrition  and  weakness  are  most 
common.  The  weakness  may  be  of  long  standing  or  it  may 
be  the  result  of  excessive  loss  of  blood  at  the  time  of  labor 
or  of  miscarriage.  The  feebleness  of  the  patient  is  the 
cause  of  the  want  of  vigor  in  the  uterus,  the  contractions  of 
which  do  not  occur  in  due  force.  Hence  protraction  of  the 
process  of  involution. 

Sub-involution  readily  passes  into  a  condition  of  chronic 
congestive  hypertrophy;  the  shape  of  the  uterus,  the  thick- 
ness of  its  walls,  may  remain  the  same,  but  it  then  becomes 
harder  and  firmer.  But  in  some  cases  this  change  into  a 
condition  of  hardness  does  not  occur,  the  uterus  remaining 
abnormally  soft,  spongy,  and  flaccid  for  a  considerable 
time.  Cases  in  which  this  latter  occurrence  is  observed  are 
those  in  which  the  nutritive  force  is  at  a  very  low  ebb;  re- 
paration is  slow,  and  a  passive  congestion  results. 

Sub-involution  is  observed  sometimes  in  conjunction 
with  inflammatory  conditions  of  the  parts  around  the 
uterus.  Thus,  in  pelvic  cellulitis,  following  labor  or  abor- 
tion, the  uterus  remains  large  and  heavy;  and  although  in 
some  cases  the  bulk  of  the  uterus  may  be  partly  due  to  ?ffi4- 


SUB-INVOLUTION    OF   THE    UTERUS.  I23 

sion  of  lymph  in  its  tissues,  yet  the  greater  part  of  it  is  evi- 
dently simply  sub-involution.  The  disturbance  going  on 
in  the  immediate  vicinity  of  the  uterus,  compression  and 
swelling  of  lymphatics,  etc.,  arrest  the  process  of  involution 
in  these  cases  of  peri-uterine  cellulitic  inflammation. 

Treatment. — There  are  two  principal  indications,  i.  To 
remove  any  impediment  which  may  exist  to  the  easy  and 
free  circulation  of  the  uterus.  2.  To  quicken  and  invigor- 
ate the  nutritive  process  in  the  body  generally.  There  are 
also  subsidiary  measures  to  be  taken. 

1.  If  there  be  a  displacement  it  must  be  rectified.  If  the 
bowels  are  in  a  chronically  loaded  state  they  must  be  re- 
lieved by  daily  gentle  aperients  or  injections.  The  hori- 
zontal position  may  be  required. 

2.  The  food  must  be  plentiful  and  of  a  highly  nutritious 
character.  In  short,  a  liberal  diet  is  necessary,  and  when 
the  appetite  is  bad,  food  must  be  given  frequently  and  in 
small  quantities  at  a  time. 

3.  SiibsiJiary  Measures. — Warm  injections  or  the  douche 
of  warm  water  once  or  twice  daily.  Ergot,  either  alone  in 
small  doses  once  or  twice  a  day,  or  together  with  iron,  fre- 
quently proves  very  useful.  Warm  sponge  baths,  warm 
sea-water  baths,  friction  of  the  skin,  fresh  air,  and  such 
general  hygienic  measures  as  may  be  specially  required, 
should  not  be  forgotten.  If  the  case  be  seen  some  weeks 
after  labor  or  miscarriage,  the  general  treatment  required 
is  much  the  same  as  for  chronic  congestion  of  the  uterus. 
Bromine  and  iodine  are  valuable  medicines  in  the  later 
phases  of  the  disorder.  Quinine  and  iron  are  of  great  ser- 
vice in  many  cases.  It  is  prubal)le  that  electricity  would 
prove  serviceable  in  some  instances. 

ATROPHY    OF    THE    UTERUS. 

Atrophy  of  the  uterus,  in  the  true  sense  of  the  word,  im- 
plies not  a  congenital  defect  as  regards  size,  but  an  acquired 
smallness. 

Atrophy  of  the  uterus  occurs  at  a  period  of  se.xual  involu- 
tion; the  organ  ceases  then  to  exercise  the  ordinary  func- 
tion, menstruation  and  the  capability  of  impregnation  com- 
ing to  an  end.  The  walls  of  the  uterus  become  under 
these  circumstances  thin,  and  the  whole  organ  smaller  than 
before.  These  changes  are  attended  with  the  further  con- 
sequence that  the  uterus  is  less  vascular  and  less  sensitive 
than  before.    The  organ  has  ceased  to  play  its  part,  and  its 


124  DISEASES   OF   WOMEN. 

condition  functionally  very  much  resembles  that  before 
puberty.  Morbid  processes  affecting  the  tissues  of  the 
uterus  are  not  unfrequently  arrested  by  the  occurrence  of 
this,  which  may  be  termed  its  natural  atrophy.  But  it  ap- 
pears that  the  uterus  may  undergo  this  senile  change  at  an 
unnaturally  early  age,  thus  constituting  a  condition  which 
Chiari*  described  as  "premature  senile  atrophy."  Sir  J. 
Y.  Simpson  f  ascribed  tliis  to  "  super-involution"  after  de» 
livery — a  questionable  theor3\ 

Premature  atrophy  of  the  uterus  might  be  expected  to 
be  found  in  women  who  have  prematurely  ceased  to  men- 
struate, but  its  occurrence  in  association  with  still  persist- 
ing ovarian  activit}'  is,  as  would  be  expected,  extremely 
rare. 

Tlie  uterus  affected  with  atrophy  of  the  character  alluded 
to  is  universally  small,  the  cervix  participates  in  the  change, 
the  vaginal  portion  becomes  shorter,  and  the  os  uteri 
smaller.  The  tissues  of  the  organ  become  somewhat 
harder. 

Atrophy  of  the  uterus  of  another  kind  may  be  produced 
by  the  operation  of  external  influences.  Thus,  when  the 
organ  is  pressed  upon  by  tumors  in  the  neighborhood,  the 
walls  may  become  very  thin.  I  have  found  the  organ  ex- 
cessively small  from  this  reason  in  some  cases  of  ovarian 
tumor  and  of  fibroid  tumor. 

Local  atrophy  occurs  in  cases  of  flexions  of  the  uterus, 
the  walls  becoming  in  many  cases  very  much  diminished  in 
thickness  at  the  part  which  is  the  seat  of  the  flexion. 

Another  kind  of  atrophy  is  that  accompanied  with  exces- 
sive dilatation  of  the  uterine  cavity,  such  as  now  and  then 
occurs  from  fluid  or  gaseous  distension  of  the  organ.  The 
uterine  walls  may  be  found  in  such  cases  excessively  thin. 
The  form  of  atrophy  here  alluded  to  has  been  described  as 
"eccentric  atrophy"  of  the  uterus. 

HYPERTROPHY    OF    THE    UTERUS. 

Congestive  hypertrophy  has  alread}'  been  described  (see 
p.  no).  Hypertrophy  may,  however,  exist  without  conges- 
tion. 

Like  many  other  organs  of  the  body,  the  uterus  is  liable 

*  "  Klinik  der  Geburtsk."    1855,  p.  371. 

f  Clinical  Lecture  on  Amenorrhoea.     j\/cJ.  Times  and  Gaz.     1861. 


SUB-INVOLUTION    OF   THE    UTERUS. 


12: 


to  variations  in  size.  This  variation  is,  however — in  indi- 
viduals in  a  slate  of  health — limited.  During  the  catamenial 
period,  the  organ  becomes  enlarged,  but  this  enlargement  is 
normally  only  temporary,  and  a  general  and  persistent  addi- 
tion to  its  bulk  only  occurs  under  abnormal  circumstances. 
The  very  considerable  growth  which  the  uterus  undergoes 
during  the  period  of  gestation  is  of  course  an  exception  to 
this  statement. 

Fig.  24.* 


The  simplest  form  of  hypertrophy  of  the  uterus  is  that 
witnessed  in  cases  where  the  uterus  is,  and  has  been,  influ- 
enced by  pregnancy  or  by  the  presence  of  a  tumor  or 
tumors  within  its  walls.  This  subject  has  been  more  fully 
considered  elsewhere  (p.  119)  in  connection  with  the  subject 


*  Fig.  24  represents  a  case  of  general  hypertrophy  of  the  uterus,  and  of 
the  cervix  uteri,  in  a  patient  affected  wiih  menorrliagia.  Amputation  of 
the  vaginal  portion  of  the  cervix  was  performed  in  this  case. 


126 


DISEASES   OF   WOMEN. 


of  chronic  congestion  of  the  uterus,  with  which  condition 
this  simple  hypertrophy  is  generally  associated.  Here  the 
enlargement  affects  the  body  and  the  cervix  of  the  uterus 
pretty  equally. 

The  most  common,  and  indeed  the  most  marked  form  of 
hypertrophy  of  the  uterus  is  witnessed  in  women  who  have 
been  pregnant,  and  just  described  (p.  121)  under  the  term 
"Sub-involution."  When  this  "involution"  does  not  occur 
regularly  and  promptly,  the  organ  is  liable  to  become 
affected  with  hypertrophy  of  a  persistent  character.     Even 

Fig.  25.* 


in  these  cases,  however,  the  degree  of  hypertrophy  wit- 
nessed, if  there  be  no  other  cause  in  operation,  is  not  very 
great.  In  hypertrophy  of  the  uterus  due  simply  to  "defec- 
tive involution"  after  deliveries,  abortions,  etc.,  the  increased 
length  of  the  organ  does  not,  I  believe,  ever  exceed  one 
inch.  (It  is  necessary  to  observe  that  this  does  not  apply 
to  any  measurement  taken  within  the  first  two  or  three 
weeks  after  the  labor  or  miscarriage.)     One  inch  increased 


*  Fig.  25  (from  Farre)  represents  longitudinal  hypertrophy  of  the  cervix, 
of  a  marked  character.  Other  illustrations  will  be  found  in  the  Chapter 
on  Prolapsus. 


SUE-INVOLUTION   OF   THE   UTERUS. 


127 


Fir,   26* 


length  usually  implies,  however,  considerable  addition  to 
the  general  bulk  of  the  organ,  and  entails  various  incon- 
veniences, which  have  been  already  particularly  described. 
Hypertrophy,  the  result  of  chronic  congestion  and  defective 
involution,  one  or  both,  is  most  palpably  evident  in  the 
cervical  region,  as  this  can  be  easily  reached  and  inspected, 
but  it  is  rarely  limited  to  this  portion. 

Hypertrophy  of  the  uterus  is  especially  liable  to  occur  in 
association  with  growth  of  fibroid  tumors  within  the  walls 
of  the  organ.  A  fibroid  tumor  of  the  uterus,  growing  in 
the  middle  of  the  thickness  of  the  wall,  not  unfrequenily 
produces  great  hypertrophy  of  the 
uterus,  for  the  uterus  may  expand 
and  grow  not  merelj'  around  the 
tumor,  but  in  every  other  part  also. 
The  bulk  of  the  uterus  may,  under 
such  circumstances,  equal  that  of  a 
cliikl's  head,  but  the  greater  part  of 
the  bulk  would  then  be  made  up  of 
the  tumor.  In  cases  of  fibrous  poly- 
pus of  the  uterus,  the  organ  grows 
sometimes  to  a  very  large  size,  but 
in  such  cases  the  uterine  walls  have 
less  thickness.  Hypertrophy  of  the 
uterus  to  a  slighter  degree  is  wit- 
nessed when  fibroid  tumors  grow 
from  its  outer  surface.  Again,  it  is 
not  rare  to  meet  with  enormous 
fibroid  tumors  growing  from  the  ex- 
ternal surface  of  a  uterus,  itself  even 
smaller  than  usual. 

Partial  hypertrophy  of  the  vaginal 
portion  is  sometimes  observed. 

Hypertrophy  with  Elongation.— ^\\t  uterus  not  unfrequently 
undergoes,  in  consequence  of  pressure,  or  in  consequence 
of  traction  in  a  particular  direction,  an  elongation  to  which 
the  term  hypertrophy  has  not  always  been  very  correctly 
applied.  This  elongation  more  particularly  affects  the  cer- 
vical portion  of  the  organ,  not  simply  that  part  which 
projects  into  the  vagina,  but  the  cervix  properly  so  called. 
Hypertrophic  elongation  of  the  cervix  constitutes  one  of 


*  Fig.  26  represents  hypertrophy  of  the  posterior  lip  of  the  os, 
malignant  character. 


of  non- 


128  DISEASES   OF   WOMEN. 

the  forms  of  prolapsus  of  the  uterus  (see  Prolapsus),  but 
it  is  also  sometimes  witnessed  when  an  ovarian  tumor 
pushes  the  body  of  the  uterus  upward,  and  thus  elongates 
the  cervix.  In  such  cases  the  walls  of  the  canal  do  not 
usually  grow,  and  the  effect  of  the  traction  is  thus  to  ren- 
der them  actually  thinner.  The  cervix  of  the  uterus  may, 
under  such  circumstances,  become  three,  four,  or  five  inches 
in  length.  The  lower  portion  of  the  cervix — i.e.^  the  vag- 
inal portion — sometimes,  however,  undergoes  a  true  hyper- 
trophy, the  result  of  which  is  that  a  conical  or  snout-like 
substance  of  considerable  size  is  then  found  occupying 
the  vagina,  nay,  even  projecting  beyond  the  ostium  vaginae. 
A  more  limited  hypertrophy  is  depicted  in  Fig.  26. 


CHAPTER  IX. 


Treatment  of  the  Various  Textural  Disorders  of  the 
Uterus — Malnutrition  of  the  Uterus,  Congestion, 
Congestive  Hypertrophy,  etc. 

General  Preventive  Treatment — Dietary  necessary — Importance  of  defi- 
cient Dietary  as  a  Cause  of  Uterine  Disease — Defects  Qualitative  and 
Quantitative — "Chronic  Starvation,"  a  Real  Disease — Its  Importance — 
Method  of  dealing  with  it — Preventive  Treatment  as  regards  Menstrua- 
lion —  Preventive  Treatment  in  Child-bed — Congestion  of  the  Uterus 
and  Congestive  Hypertrophy — General  Treatment — By  Altering  Posi- 
tion and  Shape  of  Uterus — By  Leeching,  Scarifications,  etc. — Use  of 
Hot-water  Injections — Baths  and  Watering-places — Astringent  and 
Caustic  Applications  to  the  Os  Uteri — Internal  Remedies. 

The  first  and  most  important  question  to  be  dealt  with  is 
\\\^ preventive  treatment. 

Observation  has  led  me  to  the  conclusion  that  it  is  rare  to 
tneet  with  congestion  of  the  uterus  together  with  its  vari- 
ous complications,  in  cases  where  the  uterus  was  previous- 
ly in  a  state  of  health.  An  attempt  has  been  made  to  indi- 
cate this  "  previous  state"  of  the  uterus  under  the  head  of 
"  mal-nutrition"  (undue  softness)  of  the  uterus.  That  sub- 
ject here  finds  its  practical  application. 

TREATMENT  OF  MALNUTRITION  OF  THE  UTERUS. 

Whatever  tends  to  maintain  the  body  generally  in  a  state 
of  health  tends  also  to  maintain  the  integrity  of  the  uterus. 
General  treatment  good  for  the  body  at  large  is  good  for  a 
part  of  it  also. 


TREATMENT   OF   MAL-NUTRITIOX   OF   THE   UTERUS.    12^ 

It  will  not  be  credited  by  any  one  who  lias  not  taken  the 
trouble  to  inquire  carefully  into  the  previous  habits  and 
history  of  patients  suffering  from  the  ordinary  diseases  of 
the  uterus,  how  common  it  is  in  these  cases  to  meet  with 
evidence  of  the  strongest  character  of  a  long-continued  in- 
sufficiency of  dietary,  this  insufficiency  being  in  operation 
up  to  the  time  of  the  patient  coming  under  observation,  or 
having  been  in  operation  for  a  very  considerable  period  at 
a  former  time.  It  is  thus  quite  easy  to  track  the  process  of 
commencing  ill-health  to  its  source,  and  the  facts  elicited 
by  cross-examinations  will  almost  invariably  enable  the  in- 
quirer to  say  not  only  that  the  disease  began  at  such  and 
sucli  a  time,  but  to  state  why  it  was  so. 

It  does  not  appear  that  what  may  be  termed  elementary 
nutritional  deficiency  has  been  assigned,  as  yet,  its  due 
place  in  the  etiology  of  uterine  diseases.  I  am  more  and 
more  convinced  that  the  part  it  plays  is  a  most  important 
one. 

The  dietary  must  then  be  the  first  object  of  attention. 
In  a  growing  girl  the  dietary  should  be  a  generous  one. 
Two  mistakes  are  liable  to  be  made  in  the  matter  of  tiie 
dietary:  one  relates  to  the  quality  of  the  food  given;  the 
other  to  the  quantity. 

I.  As  ri\i^arcis  the  Quality  of  the  Food. — It  is  not  uncommon 
to  meet  witli  cases  where  for  one  reason  or  another  the  food 
given  is  defective  in  quality  during  what  may  be  termed  the 
developmental  period  of  growth  of  the  uterus,  viz.,  between 
the  ages  of  twelve  and  sixteen  or  seventeen.  This  defect  is 
more  likely  to  consist,  so  far  as  my  experience  shows,  in  an 
insufficiency  of  meat  food.  The  ordinary  bread  and  butter 
wliich  constitutes  the  principal  food  in  many  boarding- 
schools  is  not  adapted  for  the  production  of  healthy  tissues. 
Meat  is  the  article  of  diet  which  I  have  generally  found  to 
have  been  deficient  in  the  dietary  of  young  women  who 
have  presented  evidences  of  mal-nutrition  of  the  uterus 
later  on. 

Motives  of  economy  sometimes  operate  to  the  exclusion 
of  a  liberal  meat  dietary.  But  in  the  middle  and  higher 
classes  of  society  these  motives  are  non-operative,  and  it  is 
not  rare  to  meet  with  cases  of  young  women  brought  up  in 
what  is  termed  a  luxurious  manner,  who  have  never  been 
permitted  during  the  growing  age  to  have  more  than  one 
meal  containing  meat  in  the  day.  This  practice  appears 
to  me,  judging  from  numerous  cases  whose  details  could  be 


130  biSEASES   OF  WOMEN. 

mentioned,  to  have  inflicted  in  those  instances  the  greatest 
injury  on  the  constitution,  and  to  have  predisposed  to  the 
grave  evils  for  the  relief  of  which  advice  was  sought  years 
later. 

2.  The  Qi/afitity. — It  is  well  known  and  generally  admitted 
that  robust  health  is  associated  with  good  appetite.  A 
good  appetite  insures  the  taking  of  sufficient  food — when 
it  can  be  procured.  The  appetite  is,  however,  too  often 
taken  as  the  guide  in  the  opposite  case,  where  it  is  deficient, 
absent,  or  capricious,  and  it  is  too  generally  supposed  that  if 
there  is  no  appetite  for  food  there  is  no  necessity  for  it. 
This  mistake — a  grievous  one — is  common  amongst  the 
public  at  large,  but  it  does  not  appear  that  it  is  sufficiently 
recognized  as  a  mistake  even  in  professional  circles.  The 
human  machine  is  kept  going  by  a  process  of  repair. 
There  is  an  incessant  waste,  and  there  must  bean  incessant 
repair  to  make  good  the  waste,  or  evil  necessarily  foUoAvs. 
It  is  true  that  the  quantity  of  food  taken  is  often  reduced 
for  a  considerable  time  without  the  individual  apparently 
suffering  materially.  The  human  frame  is  so  full  of  re- 
sources that  it  resists  for  a  long  time  the  deteriorating  in- 
fluences of  a  lessened  dietary.  The  waste  affects  some  non- 
vital  part  and  life  goes  on.  But  there  is  a  limit  to  this 
endurance.  When  the  diminished  dietary  has  been  in  op- 
eration for  a  long  time — some  months  for  instance — it  is 
almost  certain  that  in  case  of  an  individual  of  only  average 
stamina  mischief  will  result.  Of  necessity,  the  actual  quan- 
tity of  food  required  per  diem  is  larger  at  the  time  the 
growth  is  most  rapid,  and  consequently  deficiency  in  quan- 
tity is  most  felt  at  this  period.  In  the  case  of  boys  and 
young  men  there  is  not  generally  any  reluctance  to  indulge 
an  appetite  which  should  be  a  large  one,  but  in  the  case  of 
girls  it  is  not  uncommon  to  find  that  there  is  a  sort  of  feel- 
ing that  the  possession  of  a  good  appetite,  or  at  all  events 
the  innocent  gratification  of  it,  is  a  thing  to  be  deprecated. 
And  it  is  the  fact  that  many  young  women  do  themselves 
mischief  by  deliberately  taking  less  than  is  required  to 
maintain  the  body  in  a  state  of  healthy  growth. 

It  has  been  already  stated  that  the  appetite  is  often  mis- 
leading. This  appears  to  be  a  point  which  requires  to  be 
emphasized.  If  the  appetite  is  wanting  or  defective,  there 
is  probably  something  wrong,  and  steps  should  be  taken 
to  ascertain  what  has  destroyed  or  lessened  the  appetite. 
There  are  many  possible  causes  for  a  want  of  appetite — de- 


TREATMENT   OF   MAL-NUTRITION   OF  THE   UTERUS.    13I 

fective  hygienic  conditions  of  various  kinds,  actual  disease 
of  some  part  of  the  body,  etc.  But  what  should  be  recog- 
nized is,  tliat  neither  patient  nor  doctor  should  sit  down 
and  simply  allow  things  to  go  on  in  this  unsatisfactory 
manner.  Such  neglect  will  lead  eventually  to  disaster. 
The  want  of  appetite  is  perhaps  the  first  in  a  chain  of  symp- 
toms which  become  graver  and  more  serious  as  the  body 
becomes  month  after  month  debilitated  by  the  slow  starva- 
tion whicli  it  causes. 

There  is  much  reason  for  the  belief  that  the  most  impor- 
tant of  the  diseases  wliich  prove  fatal  to  young  persons — the 
tubercular  affections — have  their  origin  in  deficient  feeding. 
It  is,  at  all  events,  ceitain  that  this  is  one  of  tiie  most  im- 
portant of  the  factors  concerned  in  the  production  of  these 
diseases.  If  we  take  the^case  of  a  young  woman  growing 
up  under  such  defective  alimentary  conditions  as  have  been 
above  described,  it  is  uncertain  what  precise  effect  the 
clironic  starvation  of  which  she  is  the  subject  will  have  upon 
her — or,  in  other  words,  what  organ  of  the  body  will  first 
feel  the  attack.  It  may  be  the  lungs,  or  it  may  be  the 
uterus.  In  the  one  case  pulmonary  consumption  occurs,  in 
the  other,  disease  of  the  uterus.  My  own  experience  has 
brought  very  numerous  instances  of  the  latter  result  under 
my  notice,  and  from  some  well-marked  cases  of  the  other 
kind  which  I  have  seen  I  have  been  led  to  attribute  the  first 
step  downward  to  the  same  cause  in  each  class  of  cases, 
viz.,  defective  alimentation.  It  is  rational  to  conclude  that 
deficient  alimentation  will  have  a  tendency  to  affect  all  parts 
of  the  body;  but  it  is  in  accordance  with  experience  that  it 
affects  some  organs  more  than  others,  various  accidental 
circumstances  influencing  the  body — habits,  temperament, 
surroundings  of  various  kinds,  determining  which  particu- 
lar organ  shall  feel  the  impetus  of  the  blow  in  the  first  in- 
stance. 

Judging  from  experience  it  seems  to  me  very  desirable 
that  "chronic  starvatioji"  should  be  admitted  into  the  list 
of  recognized  diseases.  When  alimentation  is  always  defi- 
cient the  condition  of  the  body  is  one  of  chronic  starvation,* 
and  this  is  the  preliminary — in  the  majority  of  cases  per- 
haps a  necessary  preliminary — to  the  advent  of  the  various 


*  See  Annual  Address  to  the  Harveian  Society,  "On  Chronic  Starva- 
tion."    Lancet,  Jan.,  1S79. 


132  DISEASES   OF  WOMEN. 

serious  disorders  recognized  in  medical  classifications  of  dis- 
ease. 

There  are,  of  course,  hygienic  laws  to  be  complied  with. 
Fresh  air,  sufficient  clothing,  exercise  well  adjusted  to  the 
capabilities  and  requirements  of  the  body — all  these  are 
very  necessary,  but  the  maintenance  of  the  proper  degree 
of  nutritional  activity  is  of  the  first  importance.  Change 
of  air,  change  of  scene,  visits  to  watering-places,  baths,  etc., 
change  of  occupation — these  are  often  beneficial;  but  why? 
Because  they  restore  the  lost  appetite;  and  if  they  fail  in 
this, comparatively  little  benefit  is  derived. 

Having  treated  many  cases  of  commencing  uterine  dis- 
ease, characterized  as  above  described  by  softening  and 
weakness  of  the  uterus,  I  have  seen  the  great  benefits  of 
careful  and  assiduous  feeding  in  the  class  of  cases  requiring 
it,  and  have  found  this  method  of  treatment  so  universally 
successful  that  it  can  with  the  greatest  confidence  be  recom- 
mended. The  principles  which  apply  in  cases  when  the 
malady  has  to  be  cured  are,  of  course,  available  in  the  pre- 
ventive treatment. 

The  foregoing  remarks  indicate  the  importance  which  I 
attribute  to  food  and  feeding  in  the  treatment  of  chronic 
uterine  maladies.  In  a  paper  read  before  the  Obstetrical 
Society  of  London  in  1880,  I  stated  that  at  the  All  Saints' 
Institution  during  seven  years  I  had  treated  sixty-seven 
cases,  the  majority  of  which  were  cases  of  uterine  chronic 
disease  associated  with  great  general  weakness  and  a  con- 
dition of  "chronic  starvation."  "The  first  principle  of  the 
treatment  was  rest."  The  next  was  to  improve  the  general 
nutrition  of  the  body.  Most  of  the  cases  afforded  marked 
instances  of  chronic  starvation,  sometimes  of  several  years' 
standing.* 

I  give  the  above  quotation  to  show  the  lines  which  my 
practice  of  late  years  has  followed. 

In  connection  with  this  subject  it  is  next  to  be  stated  that 
Dr.  Weir  Mitcliell,f  of  Philadelphia, has  for  some  years  car 
ried  out  a  method  of  treatment  in  cases  somewhat  resem- 
bling those  treated  by  me  in  All  Saints'  Institution,  consist- 
ing in  rest,  massage,  electricity,  and  food,  all  very  systemat- 


*  See  Report  of  Sixty-seven  Cases  of  Uterine  Distortion,  etc.  "  Obst. 
Trans.,"  vol.  x.xii. 

t  "  Fat  and  Blood:  and  how  to  make  them."  London  edition,  Lippin- 
cott,  1878. 


TREATMENT   OF   MAL-NUTRITION   OF   THE    UTEROS.    I33 

ically  and  persistently  used,  and  with  results  the  success  of 
which  I  can  quite  understand  from  what  I  have  observed 
in  my  own  cases.  Dr.  Playfair  lias  recently*  made  the  pro- 
fession in  this  country  better  acquainted  with  Dr.  Weir 
Mitchell's  very  practical  and  successful  method,  and  has 
published  cases  showing  the  great  success  which  has  fi>l- 
lowed  his  adoption  of  Dr.  Mitchell's  treatment. 

Dr.  Playfair  heads  his  paper  on  tlie  subject  "Nerve 
Prostration  and  Hysteria  connected  with  Uterine  Disease." 
The  cases  are  those  in  which  the  patient  has  become  a  c<in- 
firmed  invalid,  and  in  which  there  is  or  has  been  uterine 
mischief:  "the  pain,  the  backache,  the  leucc^rrhoca,  the  difll- 
culty  in  progression,  the  disordered  menstruation,  which 
are  attendants  on  the  local  troubles,  have  ended  in  produc- 
ing a  state  of  general  disturbance  in  which  all  the  bodily 
functions  become  implicated.  The  nervous  system  is  pro- 
foundly affectetl,  the  blood  impoverished,  and  the  general 
nutrition  at  the  lowest  ebb."  There  is  wasting  of  the  fatty 
tissues,  the  appetite  is  gone,  there  is  dt^pepsia,  and  all 
e-xercise  is  abandoned.  The  patient  becomes  emotional  and 
liysterical,  and  all  efforts  at  cure  prove  unavailing. 

An  outline  of  Dr.  Weir  Mitchell's  treatment  is  as  fol- 
lows: 

1.  Absolute  repose  and  seclusion  from  home  or  other 
accustometl  influence  for  from  si.x  to  eigiit  weeks,  the 
patient  being  only  allowed  to  sit  up  gradually. 

2.  Employment  of  massage  of  all  the  muscles  twice  a  day 
f  >r  half  an  hour  at  a  time  at  first,  anil  later  on  for  an  hour 
and  a  half. 

3.  Electricity  by  the  interrupted  current  twice  daily,  the 
sponges  being  so  employed  as  to  work  all  the  muscles  suc- 
cessively. 

4.  Diet.  At  first  milk  is  given  every  three  hours — in 
small  quantities  at  first,  later  increased.  Then  more  ordi- 
nary food  of  all  kinds  is  given,  the  quantity  being  gradually 
increased,  and  soon  very  large  quantities  are  capable  of 
being  taken,  the  massage  and  electricity,  as  it  is  considered, 
enabling  the  patient  to  take  food  in  gradually  increasing 
quantities  until,  as  in  cases  related  by  Dr.  Playfair,  a  very 
enormous  amount  is  taken  daily. 

The  system  of  treatment  as  above  described  has  the  effect 
of  quickly  improving  the  strength,  in  restoring  the  lost  adi- 

*  Lancet,  iSSl. 


134  DISEASES   OF  WOMEN. 

pose  tissue,  and  enabling  the  patient  to  move  about,  and 
restoring,  in  fact,  the  lost  vitality  and  locomotive  power. 

The  massage  and  electricity  are  two  elements  in  the 
treatment  of  which  I  have  had  but  limited  experience.  I 
have  employed  baths  and  friction  of  the  skin  as  a  regular 
part  of  the  treatment  in  cases  of  great  nutritional  impover- 
ishment, in  addition  to  the  rest  and  feeding,  and  have  thus 
obtained  extremely  good  results;  but  it  seems  to  be  proved 
by  Dr.  Mitchell's  cases  that  massage  and  electricity  are 
extremely  important  additional  means,  and  there  is  no 
doubt  that  they  are  likely  to  help  materially  in  promoting 
healthy  nutritional  changes. 

It  is  to  be  remarked  that  the  incapacity  for  locomotion 
observed  in  the  class  of  cases  described  by  Dr.  Mitchell  is, 
to  my  mind,  evidence  that  the  condition  of  the  uterus  in 
his  cases  was,  as  a  rule,  that  wliich  I  have  described  as 
abnormal  softness  of  the  uterus.  The  so-called  "  hysterical  " 
element  in  these  cases  is  one  which  will  be  discussed  more 
properly  in  the  clmpter  on  the  Neuroses  of  the  Uterus. 

TREATMENT  OF  CONGESTION  OF  THE  UTERUS. 

Congestion  is  frequently  associated  with  other  conditions 
from  which  it  is  impossible  to  dissociate  them  in  practice. 
Flexions  of  the  uterus,  softening  of  the  organ,  or  hardening 
and  a  certain  degree  of  hypertrophy  are  the  principal  other 
conditions  likely  to  be  met  with. 

The  congestion  has  to  be  treated  with  due  regard  to  the 
proper  relation  subsisting  between  it  and  the  other  condi- 
tions possibly,  and  generally,  present. 

According  to  my  experience,  the  cases  are  few  in  which 
real  good  can  be  effected  without  a  careful  attention  to  the 
general  treatment,  by  the  restoration  of  the  nutritional 
activity  to  its  proper  healthy  state  as  an  integral  part  of 
the  treatment.  There  is  frequently  present  a  condition  of 
great  general  debility  out  of  which  the  patient  has  often  to 
be  slowly  dragged,  as  it  were,  by  persevering  efforts  in  this 
direction.  A  patient  who  has  been  persistentl)'  underfed 
for  three  or  four  years  will  not  be  capable  of  restoration  to 
strength  in  a  short  time;  and  when  the  uterine  congestion 
is  associated  with  such  long-standing  debility,  much  time 
may  have  to  be  spent  in  feeding  the  patient  before  the  local 
ailment  is  satisfactorily  relieved. 

The  method  of  feeding  a  patient  so  reduced,  which  I  have 


TREATMENT  OF   MALNUTRITION   OF  THE   UTERUS.    1 35 

long  practiced,  is  to  give  food  very  often,  of  such  a  kind 
that  it  can  be  easily  digested,  and  in  very  small  quantities 
at  a  time,  sometimes  every  two  hours.  Liquid  food,  soups, 
milk,  eggs  beaten  up,  etc.,  are  best  at  first;  solid  food,  also 
in  very  small  quantities,  to  be  given  later  on.  The  diges- 
tive power  is  tlien  improved  and  the  appetite  often  returns 
with  unexpected  rapitiity.  The  aadition  of  massage  and 
electricity,  according  to  Dr.  Weir  Mitchell's  plan,  promises 
to  be  very  serviceable  in  expediting  this  nutritional  improve- 
ment. The  important  principle  of  endeavoring  to  make  up 
for  past  deficiencies  by  careful  diet  cannot  be  neglected  if 
success  is  to  attend  our  efforts  to  cure  the  patient. 

My  experience  has  taught  me  much  as  to  the  power  of  food 
in  curing  disease,  particularly  in  the  cases  coming  before 
me  which  have  been  mostly  uterine.  And  in  fact  I  may  say 
that  I  have  been  thus  taught  some  very  important  lessons 
in  regard  to  their  pathology. 

The  efficacy  of  general  treatment  in  cases  of  uterine  dis- 
ease— the  "constitutional"  treatment  as  it  has  been  termed 
—  has  been  insisted  on  by  the  late  Dr.  Rigby,  Dr.  Henry  G. 
Wright  and  other  gynaecologists.  So  far  as  I  have  been 
able  to  determine,  the  "constitutional"  treatment  is  bene- 
ficial in  direct  proportion  as  it  helps  to  more  vigorously 
nourish  the  body  and  every  part  of  it,  including  the  uterus. 
Whatever  conduces  to  this  end  is  likely  to  be  of  service. 
I-'ood  is  in  fact  the  great  constitutional  remedy. 

PREVENTIVE    TRE.\T.MENT    DURING    MENSTRU.\TION. 

The  promotion  of  regularity  as  regards  quantity  and 
time  of  appearance  of  menstruation  is  very  important  in 
order  to  prevent  congestion  of  the  uterus.  Care  during 
menstruation  is  incuinbent  on  all  women,  and  even  those  in 
apparently  good  health  cannot  disregard  themselves  in 
this  respect  without  danger.  It  is  highly  important  that 
tlie  natural  congestion,  as  it  may  be  termed,  of  menstrua- 
tion should  not  be  protracted.  If  there  is  the  slightest  ten- 
dency to  disease  of  the  uterus  rest  should  be  taken  at  the 
period,  and  violent  exercise  avoided,  especially  in  conjunc- 
tion with  outward  application  of  cold.  Sitting  in  wet 
clothes  or  wet  shoes,  standing  on  damp  or  wet  floors  are 
all  sources  of  danger.     In  the  work  of  Mary  Putnam  Jacobi  * 

*  "The  Question  of  Rest  for  Women  during  Menstruation."  By  Mary 
Putnam  Jacobi.     New  York,  1877. 


13^ 


DISEASES   OF  WOMEN, 


will  be  found  the  results  of  extensive  inquiries  as  to  th^ 
necessity  for  rest  from  mental  and  other  work  during  the 
period  of  menstruation.  The  general  conclusion  is  that 
work  cannot  be  advantageously  continued  during  the  men- 
strual period  in  the  majority  of  cases. 

PREVENTIVE    TREATMENT    IN    CHILD-BED, 

Congestion  of  the  uterus  has  so  frequently  its  starting- 
point  in  a  "bad  getting-up,"  as  it  is  termed,  after  parturi- 
tion, that  some  special  remarks  are  required  on  the  subject 
of  the  preventive  treatment. 

Above  all  it  is  necessary  to  secure  healthy  and  rapid  in- 
volution of  the  uterus,  whereby  its  bulk  is  reduced,  the  nu- 
tritive changes  hastened,  and  the  restoration  to  its  normal 
size  and  bulk  effected.  The  patient  should  maintain  the 
liorizontal  posture  for  some  days,  and  should  not  be  al- 
lowed to  perform  movements  calculated  to  strain  the  ab- 
dominal muscles.  And  as  soon  as  possible  after  the  lochia 
have  ceased,  the  use  of  the  hip-bath,  or  of  the  vaginal  douche 
should  be  commenced.  Great  care  should  be  taken  to  pre- 
vent constipation  of  the  bowels.  The  diet  should  be  very 
carefully  supervised.  In  women  who  have  been  in  a  good 
state  of  health  previously  it  is  simply  necessary  to  give  or- 
dinary food  and  in  ordinary  quantities,  not  omitting  to  do 
so  even  on  the  day  following  the  delivery. 

In  those  patients  who  are  weakly  food  must  be  given 
very  often;  and  liquid  nourishment-,  as  soups,  eggs,  beef- 
tea,  etc.,  are  to  be  given  frequently  and  between  the  ordi- 
nary meals.  Night  feeding  is  very  necessary  in  weakly  wo- 
men during  child-bed,  great  exhaustion  often  setting  in 
about  four  or  five  in  the  morning;  exercise  should  be  taken 
in  moderation  at  first;  walking  should  not  be  commenced 
until  two  or  three  weeks  have  elapsed.  It  is  usually  advis- 
able to  apply  a  moderate  support  to  the  abdomen  by  means 
of  an  elastic  bandage.  Very  great  benefit  will  be  derived 
from  attending  to  these  simple  rules,  and  it  is  very  certain 
that  a  neglect  of  them  has  frequently  the  result  of  originat- 
ing a  troublesome  and  painful  disease.  It  is  important,  as 
a  further  means  of  securing  perfect  contraction  of  the  uter- 
us after  delivery,  to  induce  the  patient  to  suckle  her  child, 
although  this  course  cannot  from  the  debility  of  the  patient 
always  be  recommended.  In  women  who  are  liable  to 
abortions,  the  majority  of  whom  are  affected  with  uterine 
flexion,  it  is  necessary  to  take  double  precautions;  we  fre- 


TREATMENT   OF   MAL-NUTRITION    OF   THE    UTERUS.    1 37 

quently  find  that  the  uterus  becomes  diseased  from  the  fact 
that  the  pregnancies  rapidly  succeed  each  oilier,  the  uterus 
not  having  recovered  its  natural  size  when  it  becomes 
again  occupied  by  an  ovum.  In  such  cases,  unless  care  be 
exercised,  the  liability  to  abortion  is  perpetuated,  and  the 
local  evil  intensified.  We  must  insist  on  the  necessity  for 
allowing  the  uterus  a  period  of  rest;  this  is  equally  neces- 
sary after  an  abortion,  and  after  an  ordinary  labor;  in  many 
cases  the  habit  of  abortion  is  only  to  be  broken  through  by 
enforcing  a  separation  of  the  husband  and  wife  for  some 
months,  during  which  time  efforts  are  to  be  made  to  re- 
duce the  uterus  to  its  normal  size  and  to  its  natural  condi- 
tion. There  can  be  no  doubt  that  by  judiciously  watching 
over  and  supervising  the  function  of  parturition,  and  reg- 
ulating the  conduct  of  the  patient  afterward,  we  can  effect 
much  good  in  cases  where  the  uterus  is  liable  to  fall  into  a 
state  of  chronic  enlargement  and  congestion. 

The  congestion  which  is  apt  to  occur  after  labor  is  of  a 
passive  kind;  the  large  size  of  the  uterus  enables  it  to  hold 
much  blood.  It  is  also  softer  than  usual,  and  the  great 
danger  of  this  undue  softness  and  weight  of  the  organ  is 
that  there  thus  arises  a  strong  predisposition  to  severe  dis- 
placement of  the  organ.  The  order  of  events  is  frequently: 
I.  Defective  involution;  2.  Congestion;  3.  Displacement, 
including  fle.xion;  4.  Congestion  created  and  kept  up  by 
the  flexion;  5.  Hindrance  to  further  perfection  of  the  invo- 
lution by  the  other  already  mentioned  conditions. 

GENER.A.L  TRE.ATMENT  OF  CONGESTIOX  AND  CONGESTIVE 
HVPERTROPHY  OF  THE  UTERUS. 

It  is  undoubtedly  the  fact  that  distortions  of  the  uterus 
are  in  great  part  the  cause  of  congestion  of  the  uterus  as 
we  meet  with  it  in  practice.  When  the  congestion  is  a  me- 
chanical congestion  it  can  be  quickly  and  materially  re- 
lieved by  removing  the  cause — that  is  to  say,  by  taking 
steps  to  restore  the  uterus  to  its  normal  shape  and  position, 
thus  allowing  the  blood  in  the  uterine  vessels  more  freely 
to  circulate.  The  uterus  is  in  many  cases  extremely  amen- 
able to  mechanical  influences  acting  from  without.  Thus 
in  a  case  of  anteflexion  the  placing  of  the  patient  on  the 
back  will  help  to  remove  congestion  associated  with  dislo- 
cation, whereas  in  cases  of  congestion  due  to  retroflexion 
the  reverse  treatment  will  be  necessary.  So,  again,  the 
knee  and  elbow  position,  by  raising  the  fundus  uteri,  often 


138  DISEASES   OF  WOMEN. 

SO  assists  the  uterine  circulation  tiiat  congestion  is  thereby 
relieved.  These  points  will  be  more  fully  enlarged  upon  in 
the  chapter  on  the  Treatment  of  Flexions.  This  method  of 
treating  congestion  of  the  uterus  is  of  primary  importance, 
and  it  can  frequently  be  carried  out  without  resort  to  in- 
struments at  all.  The  effects  producible  are  sometimes  ex- 
tremely rapid,  and  the  principle  of  treatment  is  so  simple 
that  it  is  readily  understood  and  applied  in  practice. 

The  practice  of  leeching  the  uterus  in  order  to  remove 
congestion  is  in  its  way  a  mechanical  method  of  treatment. 
It  is  one  which  was  very  much  practiced  a  few  years  ago, 
and  it  is  still  largely  employed  by  practitioners  who  are  not 
practically  aware  of  the  intimate  connection  as  cause  and 
effect  subsisting  between  flexions  and  chronic  congestion  of 
the  uterus,  and  who  have  not  had  opportunities  for  observing 
the  extreme  rapidity  with  which  the  congestion  as  a  rule 
subsides  when  the  uterus  is  so  treated  that  its  circulation  is 
no  longer  obstructed.  The  withdrawal  of  blood  from  the 
congested  os  uteri  by  leeches  removes  for  the  moment  the 
congestion  of  that  part  (though  it  has  less  effect  on  the  con- 
gestion of  the  body  of  the  uterus),  and  when  the  process  is 
repeated  for  some  weeks  two  or  three  times  a  week,  has,  no 
doubt,  an  appreciable  effect  of  a  beneficial  character.  But 
if  the  same  result  can  be  obtained  by  other  and  more  sim- 
ple means,  and  without  taking  away  blood,  and  therewith 
strength,  the  simpler  method  will  in  the  end  com.e  to  be 
preferred.  On  the  view  which  supposes  the  congestion  to 
be  a  sort  of  disease  of  itself,  the  leeching  would  undoubted- 
ly commend  itself  as  rational;  but  if  the  congestion  be  a 
mere  mechanical  result  of  some  other  condition  of  the  uter- 
us, obviously  the  rational  course  to  pursue  will  be  to  deal 
with  that  other  condition,  in  the  first  place  at  all  events. 
Leeches  will,  however,  be  found  useful  in  cases  where  the 
uterus  has  become  hypertrophied  as  well  as  congested. 

Certain  manipulations  necessary  in  applying  leeches  must 
be  mentioned.  Unpleasant  or  inconvenient  results  are  apt 
to  occur  when  the  leeches  attach  themselves  either  within 
the  OS  uteri,  or  on  the  w'alls  of  the  vagina.  A  moderate- 
sized  speculum  is  to  be  first  introduced,  so  that  its  upper 
extremity  touches  the  vaginal  portion  of  the  cervix  at  every 
point,  and  a  small  piece  of  lint  is  next  inserted  in  the  os  it- 
self. The  leeches  (three  or  four  in  number)  are  then  pushed 
up  the  tube,  and  allowed  to  fix  themselves  on  the  exposed 
portion  of  ilie  cervix.     It  may  be  necessary  to  use  an  injeg- 


TREATMENT   OF   MAL-NUTRITION   OF  THE    UTERUS.    1 39 

tion  of  tepid  water  previously  to  applying  the  leeches,  and 
to  remove  the  discharge  covering  the  surface  of  the  cervix 
by  means  of  a  piece  of  lint.  Wlien  the  leech  attaches  itself 
to  the  interior  of  the  os,  or  to  tiie  vaginal  wall,  the  patient 
usually  experiences,  especially  in  the  former  case,  sharp 
pain.  To  detach  the  leech  under  such  circumstances,  an 
injection  of  salt  and  water  is  to  be  used.  It  must  not  be 
forgotten  that  the  bleeding  from  leech  bites  on  the  os  uteri 
is  sometimes  very  profuse,  it  may  be  even  alarming. 

Scarifications  o\  punctures  of  tiie  congested  uterine  cervix, 
either  externally  on  the  surface  of  the  vaginal  portion,  or 
within  the  canal,  are  of  great  use  in  some  instances,  espe- 
cially in  reducing  the  size  in  cases  of  hypertrophy  of  the 
part.  The  remedy  is  applicable  to  the  same  class  of  cases 
as  those  requiring  leeches.  A  number  of  slight  scarifica- 
tions are  better  than  two  or  three  deeperones.  In  perform- 
ing scarification  of  tlie  cervical  canal,  a  small  knife  of  pecu- 
liar shape  and  construction  is  necessary. 

Use  of  Hot-water  Injections. — Of  late  years  the  efficacy  of 
hot-water  injections — temperature  100°  to  110° — has  been 
frequently  observed  in  the  treatment  of  uterine  congestion. 
Dr.  Emmet,  of  New  York,  largely  employed  it,  and  I  have 
for  the  last  two  or  three  years  rather  extensively  recom- 
mended it.  On  the  whole  there  seem  to  be  good  reasons 
for  avoidance  of  cold  water  for  injections  or  affusions  to  the 
uterus.  There  was  formerly  a  notion, which  I  myself  shared, 
that  cold  water  was  a  good  application  in  cases  of  conges- 
tion of  the  uterus.  I  no  longer  think  so.  The  hot-water 
high-temperature  douche  may  be  employed  twice  a  day; 
the  quantity  used  may  be  one  or  two  pints  or  more. 

In  cases  of  congestive  hypertrophy  of  the  cervix  uteri; 
when  the  os  presents  nodular  masses  instead  of  the  natural- 
shaped  orifice,  the  repeated  use  of  hot  water  as  above  men- 
tioned is  a  valuable  assistance  in  promoting  absorption. 

[As  bearing  on  this  subject  I  insert  here  Dr.  Emmet's  re- 
marks on  the  use  of  hot-water  vaginal  injections  in  uterine 
disease.  (Emmet's  "Principles  and  Practice  of  Gynaecol- 
ogy," second  edition,  pp.  81  and  119.) 

"  Hot- water  vaginal  injections,  of  different  degrees  of 
temperature,  according  to  the  circumstances  of  the  case, 
will  prove  an  invaluable  aid  in  the  treatment  of  all  uterine 
diseases.  It  is,  therefore,  of  the  greatest  importance  that 
tiiey  should  be  administered  properly.  When  given  in  the 
upright,  or  sitting  position,  the  effect   is   very  little  mgre 


I40  DISEASES   OF   WOMEN. 

than  to  wash  out  the  vagina.      The  full  benefit  cak  be  or;- 

TAIXED  BY  ADMINISTERING  THEM  ONLY  WHILE  THE  PATIENT 
IS  LYING  ON  HER  BACK,  AND  SHE  CANNOT  EFFICIENTLY  GIVE 
THEM    TO    HERSELF.       It    is    ALSO    NECESSARY    THAT    HER     HIPS 

SHOULD  BE  ELEVATED,  and  the  quantity  of  water  used  should 
not  be  less  than  half  a  gallon  for  each   injection. 

''  A  bed-pan  of  proper  shape  and  size  is  indispensable  to 
protect  the  clothing  of  the  patient.  The  one  known  in  the 
Crocker}'  shops  as  the  English  bed-pan,  but  now  somewhat 
out  of  use,  answers  the  purpose  very  well.  For  temporary 
use,  the  India-rubber  inflated-cushion  bed-pan  will  answer, 
but  it  is  liable  to  stick  together  from  the  effects  of  the  hot 
water. 

"The  shovel-shaped  French  bed-pan,  more  in  general  use 
in  the  sick-room,  does  not  answer  for  this  purpose,  as  it  al- 
lows the  clothing  of  the  patient  to  become  wet.  When 
using  the  regular  bed-pan,  it  is  necessary  to  place  the  pa- 
tient so  far  forward  on  it  that  her  weight  will  not  tilt  it  up. 
Or  the  handle,  which  is  hollow,  may  be  turned  to  one  side, 
and  a  piece  of  large  India-rubber  tubing  stretched  over  it 
to  allow  the  water  to  pass  off  into  a  receptacle  placed  along- 
side of  the  bed.  For  use  in  my  private  hospital  I  have  this 
form  of  bed-pan  made  of  copper,  and,  instead  of  so  large  a 
handle,  there  is  a  small  spout  wliich  can  be  kept  closed 
when  not  needed,  by  a  cap  over  it.  When  a  large  injection  is 
given,  the  cap  can  be  removed,  and  a  small  piece  of  tubing 
placed  over  the  spout  will  carry  off  the  water. 

"The  injection  can  be  better  administered  to  the  patient 
after  she  is  undressed  for  the  night  and  in  bed.  She  should 
be  placed  near  the  edge  of  the  bed  with  her  hips  elevated 
as  much  as  possible  by  the  bed-pan,  and  a  small  pillow 
under  her  back,  the  lower  limbs  being  flexed.  Her  body 
must  be  covered,  to  protect  her  from  cold,  and  her  position 
made  perfectly  comfortable;  when  the  bed  is  a  soft  one,  a 
broad  board  should  be  placed  under  the  pan  to  prevent  it 
from  sinking  down  by  the  weight  of  the  patient,  and  to 
keep  the  hips  elevated.  The  vessel  of  hot  water  is  placed 
on  a  chair  by  the  bedside,  and  the  nurse  passes  the  nozzle 
of  the  syringe  over  the  perineum  into  the  vagina,  directing 
it  along  the  recto-vaginal  wall  until  it  has  reached  the  pos- 
terior cul  de  sac.  The  water  must  be  thrown  in,  at  first, 
very  carefully,  until  the  vagina  has  become  distended.  If 
the  nozzle  is  not  properly  introduced,  the  stream  of  water 
may  be  thrown  directly  into  the  uterine  canal.     The  forci- 


TREATMENT   Ot   MAL-NUTRITION   OF   THE    UTERUS.    I4I 

ble  entrance  of  any  fluid  into  the  undilated  uterus  causes 
intense  pain,  and  frequently  alarming  symptoms  of  nervous 
prostration  or  collapse;  and  sometimes  it  is  the  cause  of  an 
attack  of  cellulitis.  At  the  completion  of  the  injection,  the 
vagina  can  be  emptied  by  depressing  the  perineum  for  a 
few  seconds,  with  the  finger  on  the  noz/Ac  of  the  syringe  be- 
fore withdrawing  it,  and,  as  the  bed-pan  is  removed,  a  nap- 
kin should  be  placed  against  the  vaginal  outlet  to  absorb 
any  water  which  may  have  been  retained. 

"When  circumstances  prevent  the  injections  being  thus 
administered,  it  is  better  to  use  a  fountain,  siphon,  or 
syringe, than  that  the  patient  should  attempt  to  give  them 
to  herself.  This  mode,  however,  can  only  be  regarded  as  a 
substitute,  for  it  is  never  as  efTicacious.  In  any  event  the 
same  elevated  position  of  the  hips  is  necessary.  A  steady 
stream  is  never  as  serviceable  as  the  interrupted  current 
from  a  Davidson's  syringe. 

"  Hence  it  would  seem  as  if,  in  addition  to  the  heat  of  the 
water,  the  jet  from  the  syringe  acts  as  a  stimulus  to  e.xcite 
the  blood-vessels  to  contraction."] 

Baths  and  \]'ateriih:;-placcs. — In  obstinate  cases,  the  great- 
est benefit  is  sometimes  derived  from  the  internal  and  ex- 
ternal use  of  mineral  waters  of  various  kinds;  the  effects 
produced  being  dependent  partly  on  the  change  of  scene 
and  occupation,  partly  on  the  increased  activity  of  the  skin 
induced  b\'  the  use  of  the  baths,  and  partly  on  some  special 
action  of  the  waters  used.  The  choice  of  a  watering-place 
is  a  matter  of  some  moment.  In  cases  complicated  with 
dyspepsia  and  with  defective  action  of  the  abdominal  cir- 
culation, Vichy  or  Hombourg  may  be  recommended. 
Where  the  action  of  the  abdominal  viscera  is  sluggish,  and 
where  there  is  great  constipation,  the  baths  of  Carlsbad  or 
Marienbad  are  very  useful,  especially  in  the  case  of  patients 
who  have  been  in  the  habit  of  indulging  too  much  in  the 
pleasures  of  the  table.  Many  others  might  be  mentioned, 
equally  efficacious  in  improving  the  condition  of  the  ab- 
dominal circulation  and  the  state  of  the  digestive  organs, 
such  as  the  waters  of  Plillna,  Seidlitz,  Purton,  etc.,  which 
contain  sulphate  of  magnesia  and  soda,  and  are  therefore 
of  an  aperient  character.  In  cases  where  we  desire  to  act 
chiefly  on  the  skin,  and  to  effect  a  derivation  to  the  surface, 
thermal  waters  offer  advantages;  the  waters  of  Wildbad, 
Schlangenbad,  Gastein,  Clifton,  Buxton,  etc.,  deserve  men- 
tion  in   this   respect.     Warm    sea-water   baths  act  in   like 


142  DISEASES   OF   WOMEN. 

manner;  they  are  very  efficacious,  and  have  the  additional 
advantage  of  being  accessible.  There  are  cases  in  which 
the  uterus  and  pelvic  organs  generally  appear  to  be  in  an 
atonic  relaxed  state,  and  for  the  relief  of  this  class  of  pa- 
tients chalybeates  are  found  most  serviceable.  The  waters 
of  Schwalbach,  Pyrmont,  Spa,  Driburg,  Kissingen,  Fran- 
zensbad,  and  Fachingen,  are  the  best  adapted  for  patients 
suffering  from  the  above  symptoms,  associated  as  they 
usually  are  with  anaemia,  pallidity  of  the  surface,  tendency 
to  headaches,  etc.  The  iodo  bromated  w^aters  of  Kreuz- 
nach,  Hall,  Durkheim,  and  Krankenlieil,  are  specially  to  be 
recommended  in  cases  of  the  more  chronic  kind,  especially 
when  the  uterus  is  the  seat  of  indurations,  however  caused. 
The  Woodhall  Spa  in  Lancashire  enjoys  a  reputation  for 
qualities  analogous  to  those  of  Kreuznach.  For  neuralgic 
or  rheumatic  cases,  Wiesbaden,  Baden-Baden,  Ems,  and 
Bath  enjoy  deserved  repute.  In  cases  where  it  is  consid- 
ered desirable  to  administer  iron  in  small  quantities,  to- 
gether with  an  aperient,  waters  such  as  those  of  Kissingen 
or  Selters  are  the  best.  The  baths  of  Driburg  have  been 
found  peculiarly  efficacious,  taken  during  pregnancy,  in 
cases  where  there  is  a  tendency  to  disease  of  the  foetus;  the 
waters  in  question  are  chalybeate,  but  contain  also  lime  in 
solution.* 

Astringefit  and  Caustic  Applications  to  the  Os  Uteri. — As 
subsidiary  measures  these  local  applications  are  frequently 
of  great  service. 

Solutions  of  alum  or  of  tannic  acid,  or  the  latter  in  form 
of  oak  bark  decoction,  are  the  astringents'  most  commonly 
employed  in  the  form  of  an  injection  used  once  or  twice 
daily.  Many  other  astringents  have  been  also  employed 
with  advantage.  Caustic  applications  have  been  very  fre- 
quently employed  in  cases  where  the  malady  supposed  to 
be  present  was  ulceration  of  the  os  uteri,  and  in  another 
class  of  cases  also  where  the  lips  of  the  os  are  hypertrophied 
(congestive  hypertrophy).  The  caustic  agents  used  have 
been  of  various  kinds,  from  the  solid  nitrate  of  silver,  com- 
paratively mild  in  its  action,  to  the  acid  nitrate  of  mercury 
or  caustic  potash.  The  stronger  caustics  have  been  rather 
frequently  employed  to  melt  down  and  actually  destroy  the 
nodular  projecting  lips  of  the  os  uteri  as  well  as  to  produce 

*For  further  information  on  the  subject  of  baths,  see  Dr.  AUhaus' 
work,  "  The  Spas  of  Europe,"     London;  TrUbner. 


TREATMENT   OF   MAL-NUTRITION    OF   THE    UTERUS.    1 43 

a  healing  of  the  so-called  ulcers.  The  use  of  severe  caus- 
tics in  this  manner  had  a  powerful  effect,  and,  in  not  a  few 
cases,  not  only  removed  the  hypertrophy  but  produced  a 
closure  of  the  aperture  of  the  os  uteri,  with  consequent 
grave  inconveniences.  When  the  lips  of  the  os  are  fissured 
deeply,  and  present  nodular  projections,  the  best  treatment 
consists  in  first  of  all  reducing  the  bulk  by  persevering  with 
daily  injections  of  hot  water,  and  afterward  repairing  the 
lacerations  by  a  plastic  operation  (see  chapter  on  Lacera- 
tions of  the  Cervix  Uteri). 

The  waters  of  Kreuznach  are  specially  serviceable  in  the 
concentrated  form  in  cases  of  chronic  congestive  hypertro- 
phy of  the  uterus  and  cervix,  their  use  being  continued  for 
some  few  weeks  at  a  time. 

The  milder  caustic  agents  are  of  service  in  accelerating 
the  removal  of  hypertrophies  of  the  lips  of  the  os  uteri. 
The  solid  nitrate  of  silver  and  the  iodine  liniment,  or  the 
liquor  (which  latter  is  the  weaker)  of  the  British  Pharma- 
copoeia, are  the  agents  I  prefer.  Strong  solution  of  bromine 
is  also  a  useful  agent  for  the  purpose.  These  agents  are 
applied  on  cotton- wool  by  means  of  the  speculum:  the  os 
and  cervix  being  well  exposed,  the  secretions  are  to  be  re- 
moved and  the  surface  well  dried  by  means  of  a  piece  of 
lint  or  cotton-wool,  and  the  caustic  then  applied. 

The  only  cases  in  which  stronger  agents  seem  admissible 
are  those  in  which  there  is  a  small  growth  which  requires 
actual  removal — for  instance,  those  in  which  the  interior  of 
the  OS  presents  those  excrescences  or  developments  of  the 
mucous  membrane  known  as  mucous  polypi;  those  cases  also 
in  which  the  mucous  follicles  around  the  os  become  swelled 
out  and  distended,  presenting  the  little  round  enlargements 
known  as  the  Nabothian  bodies.  In  the  application  of  the 
stronger  caustics,  we  have  an  expeditious  mode  of  dealing 
with  the  pathological  conditions  in  question. 

Whenever  the  strong  caustics  are  used,  very  great  care  is 
necessary  to  prevent  the  tissues  adjoining  the  cervix  uteri 
from  being  injured.  These  tissues  must  be  guarded  in  a 
suitable  manner  during  the  operation,  and  precautions  used 
to  prevent  the  caustic  applied  to  the  surface  of  the  cervix 
from  coming  into  contact  with  the  opposed  surfaces  of  the 
vagina,  when  the  operation  is  over,  and  the  speculum  with- 
drawn. 

The  actual  cautery  has  been  a  favorite  remedy,  especially 
in  France,  in  the  treatment  of  chronic  induration  or  inflam- 


144  DISEASES   OF   WOMEN. 

mation  of  the  vaginal  portion  of  the  cervix  uteri.  The  ap- 
plication is  made  through  a  horn  speculum,  specially  con- 
structed for  the  purpose,  and  is  repeated  at  intervals  of  a* 
few  days,  each  portion  of  the  indurated  surface  being  thus 
successively  covered  with  eschars. 

Internal  [Remedies. — On  the  supposition  that  proper  meas- 
ures are  being  taken  to  remove  the  cause  of  the  congestion 
and  improve  the  uterine  circulation,  we  have  to  consider 
what  other  internal  treatment  is  required.  Ergot  given  at 
intervals  in  small  doses,  or  by  the  subcutaneous  method  is 
one  of  the  internal  remedies  most  appropriate  for  reducing 
chronic  uterine  congestion.  Probably  next  in  order  stands 
bromine,  or  mineral  waters  containing  it.  The  Kreuznach 
water  is  one  of  these,  and  its  use  continued  over  many 
weeks  has  a  considerable  effect  in  most  instances.  Bromide 
of  potassium  may  be  given  as  a  medicine,  ten  or  fifteen 
grains  twice  a  day.  It  may  also  be  used  as  an  injection  for 
the  vagina.  The  Kreuznach  water  (in  the  more  or  less 
concentrated  form)  can  be  very  usefully  thus  employed. 
Its  topical  action  on  the  uterus  is  undoubtedly  good,  espe- 
cially in  cases  where  there  are  hypertrophies  of  the  os  uteri 
present. 

A  mild  mercurial  course,  following  the  suggestion  of  Dr. 
Oldham,  has  been  often  employed  in  order  to  reduce  the 
size  of  the  organ  in  cases  of  chronic  congestive  hypertro- 
phy. The  remedy  is  undoubtedly  efficacious  in  some  in- 
stances. But  it  requires  care,  for,  if  the  patient  be  very 
weakly,  it  may  do  more  harm  than  good. 

Relief  of  Pain. — There  are  many  cases  of  congestion  of 
the  uterus  in  which  immediate  treatment  of  a  palliative 
character  is  required  for  the  relief  of  pain. 

The  remedies,  opiates,  fomentations,  etc.,  which  may  be 
advantageously  employed  under  such  circumstances  will  be 
described  in  the  chapter  on  Treatment  of  Flexions. 


CHAPTER  X. 

Abnormal  Conditions  of  the  Lining  of  the  Uterus. 

General  Employment  of  term  Endometritis — Explanation  of  these  Cases 
— Cause  most  frequently  Retention  in  Uterine  Cavity  of  Irritating 
Discharges,  Retention  being  due  to  Uterine  Distortion — Importance 


THE   LINING  OF  THE   UTERUS.  I45 

of  Drainage  of  Uterine  Cavity — Fungous  Condition  of  the  Lining  of 
the  Body  of  the  Uterus  shown  to  be  really  Congestive  Hypertrophy  of 
the  Mucous  Membrane. 

The  terms  endometritis,  endocervicitis,  have  been  em- 
ployed to  designate  the  condition  of  the  lining  membrane 
of  the  interior  of  the  body  of  the  uterus  and  of  the  cervix, 
respectively  met  with  in  cases  of  so-called  inflammation  of 
the  uterus.  And  these  affections  (endometritis  and  endo- 
cervicitis) constitute  for  several  gynaecologists  of  repute 
substantial,  important,  and  independent  diseases.  The 
piesence  of  pain,  coupled  with  a  copious  discharge  from  the 
uterine  cavity,  is  taken  to  imply  that  the  aft'ection  is  mainly 
endometritis,  and,  further,  that  it  is  a  primary  affection. 
But  there  are  good  grounds  for  disputing  the  accuracy  of 
this  view. 

Endometritis  does  probably  occur  as  a  separate  and  dis- 
tinct ailment.  Thus,  one  of  the  effects  of  a  severe  chill  is 
to  set  up  a  morbid  condition  of  the  lining  of  the  uterus, 
which  becomes  irritated  in  common  with  the  tissues  of  the 
uterus  generally.  The  lining  of  the  uterus  may  also  be 
irritated  and  inflamed  by  various  applications  from  without. 
And  there  is  no  doubt  also  that  traumatic  influences  acting 
on  the  lining  of  the  uterus — laceration  by  the  point  of  the 
sound,  for  instance — may  set  up  dangerous  irritation.  In 
the  latter  case,  however,  we  have  a  real  pyaemic  process 
introduced.  Apart  from  traumatic  influences,  it  may  be 
said  that  endometritis  is,  as  a  distinct  disease,  not  by  any 
means  common. 

The  importance  which  " endometritis"  holds  in  the  esti- 
mation of  some  uterine  pathologists  necessitates  a  discus- 
sion in  this  place  of  the  whole  question.  Those  who,  reject- 
ing as  unphilosophical  and  untrue,  when  tested  clinically, 
the  theory  of  all  uterine  maladies  being  situated  at  the 
cervix,  and  who  have  contended  for  the  body  of  the  uterus 
having  a  little  more  attention  paid  to  it,  have  been  them.- 
selves  divided  into  two  camps.  Some  have  held  that  the 
tissues  of  the  walls  of  the  body  of  the  uterus  are  affected  with 
inflammation;  others  consider  \.\\^  liuitig  of  the  body  of  the 
uterus  to  be  the  principal  seat  of  the  disorder. 

I  have  all  along  expressed  my  agreement  with  those  who, 
like  Scanzoni,  contend  for  the  importance  of  the  affections 
of  the  body  of  the  uterus. 

The  absence  of  a  free  outlet  for  the  uterine  secretions  is 
a  fertile  source  of  irritation  of  the  uterine  lining.     Thus  the 


I46  DISEASES  OF  WOMEN. 

flexions  of  the  uterus  are  causes  of  such  irritation,  leading; 
as  they  do  so  frequently,  to  a  partial  and  valvular  closure 
of  the  internal  os  uteri.  The  fluid  collects  in  and  dis- 
tends the  body  of  the  uterus,  is  retained  and  becomes  irri- 
tating. 

Excessive  discharge  from  the  interior  of  the  body  of  the 
uterus  is  in  so  many  cases  obviously  connected  with  an 
obstruction  at  the  internal  os  uteri  leading  to  retention  of 
the  secretion  within  the  uterus,  that  it  is  impossible  to 
escape  the  conclusion  that  it  is  this  obstruction  which  is 
responsible  for  the  excessive  secretions.  Under  the  head 
of  '•  Flexions"  of  the  uterus  this  matter  will  require  further 
development;  but  here  I  would  state  that  the  facts  and  the 
results  of  that  special  treatment  for  endometritis  which  is 
in  favor  with  some  practitioners  equally  fall  in  with  this 
view  of  the  case. 

Accepting,  therefore,  the  assertion — which  is  undeniable 
— that  in  certain  cases  the  lining  of  the  body  of  the  uterus 
is  in  a  disordered  state,  evidenced  by  purulent  or  offensive 
discharges  therefrom;  and,  putting  on  one  side  cases  of 
cancer,  cases  (very  rare)  of  tuberculosis  of  the  uterus,  cases 
of  gonorrhoea  and  s\'philis,  I  continue  to  hold  the  opinion, 
expressed  in  the  last  edition  of  this  work^  that  this  disor- 
dered state  of  the  lining  of  the  body  of  tlie  uterus  is  gener- 
ally the  result  of  retention  of  natural  secretions  and  the 
irritation  proceeding  therefrom. 

Any  one  who  has  treated  cases  of  flexion  of  the  uterus  is 
familiar  with  the  fact  that  the  uterine  body  is  frequently 
enlarged  and  distended  by  accumulation  of  fluid  within  it. 
This  fluid  escapes  from  time  to  time^  but  until  this  flexion 
is  relieved  the  accumulation  is  apt  to  recur.  When  men- 
struation occurs  under  these  circumstances  the  menstrual 
products  are  also  apt  to  be  detained  in  utero.  The  ''pe- 
riod "  is  protracted  and  may  be  ver}^  painful.  The  retained 
products  irritate  the  interior  of  the  uterus,  become  broken 
up,  mixed  with  further  secreted  watery  fluid,  and  finally 
escape  in  gushes  as  a  puriform  fluid.  Dysmenorrhoea, 
menorrhagia,  leucorrhoea,  are  all  symptoms  which  may  be 
mixed  up  with  such  retention  of  fluid  in  utero,  and  there- 
fore it  is  impossible  to  dissociate  their  consideration  from 
the  question  of  possible  endometritis,  and  the  possibly 
altered  condition  of  the  lining  of  the  uterus  must  of  course 
be  considered  in  conjunction  with  these  symptoms  and  their 
connec'"ion  pointed  out.     In  this   place  we  are  concerned 


THE   LIXIXG   OF  THE   UTERUS.  I47 

with  the  question  as  to  the  substantiality  of  endometritis 
as  a  distinct  disease.  It  really  appears  to  be,  in  the  major- 
ity of  cases,  but  an  effect,  an  accident — so  to  speak — of 
other  concomitant  disorders  of  the  uterus:  important,  no 
doubt,  as  an  effect,  but  still  an  effect.  Constituting  indis 
putably  a  source  of  discomfort  and  giving  rise  to  various 
symptoms,  but  not  a  primary  condition  in  the  proper  sense 
of  the  word. 

The  key  to  the  proper  understanding  of  most  of  the  cases 
of  so-called  endometritis  is  the  due  recognition  of  the  im- 
portance of  drainage  of  the  uterine  cavity.  Provision  must 
be  made  for  escape  of  the  secretions,  and  the  conditions 
capable  of  producing  retention  of  these  products  must  be 
understood.  When  the  uterus  has  a  shape  resembling  that 
of  a  retort  the  circumstances  are  not  favorable  to  free  and 
easy  drainage  of  its  interior,  and  attentive  observation  of 
two  or  three  cases  of  chronic  flexions  of  the  uterus,  associ- 
ated with  so-called  endometritis,  will  make  it  evident  to  the 
inquirer  that  the  real  relation  subsisting  between  the  bend- 
ing of  the  uterus  and  the  presence  of  fluid  and  profuse 
secretions  from  the  uterine  interior  is  one  of  cause  and 
effect. 

The  analogy  between  puriform  discharge  from  the  uterus 
and  chronic  cystitis  due  to  stricture  of  the  urethra,  is,  so  far 
as  possible,  complete.  In  both  we  have  distention  of  a 
muscular  organ  to  an  unnatural  degree  with  secreted  pro- 
ducts, irritation  of  the  interior  by  the  retained  product, 
alterations  of  the  fluid  secreted,  etc.  The  stricture  of  the 
urethra  is  analogous  to  the  bend  in  the  uterus — both  ob- 
struct excretion. 

The  various  effects  witnessed  in  cases  of  so-called  endo- 
metritis are  then  explainable  on  the  deficient  drainage 
hypothesis.  The  view  here  expressed  has  been  opposed 
and  criticised  in  many  quarters,  but  it  is  sufficient  to  exam- 
ine the  details  of  cases  published  with  the  endeavor  to  con- 
trovert these  views,  in  order  to  obtain  evidence  corroborative 
of  their  accuracy.  The  endometritis  theory  of  uterine  dis- 
ease has  suggested  the  necessity  of  making  applications  of 
caustic  or  other  materials  to  the  interior  of  the  uterus  in 
order  to  get  at  the  root  of  the  supposed  disease.  This 
treatment  has  been  found  very  serviceable  in  relieving  pa- 
tients of  the  symptoms  which  they  presented.  But  the 
very  process  adopted  of  application  to  the  interior  of  the 
uterus  of  the  cauterizing  agents,  of  necessity  so  alters  the 


148  DISEASES  OF  WOMEN. 

shape  of  the  uterus  as  to  abolish  for  the  time  being  the 
retention.  The  instruments  inserted  are  generally  nearly 
straight.  The  canal  of  the  cervix  is  indeed  sometimes  arti- 
ficially dilated  in  order  more  easil}'  to  apply  the  remedy, 
and  by  these  means  the  flexion,  which  previously  existed, 
is  of  necessity  more  or  less  destroyed.  Thus  one  effect,  at 
all  events,  is  produced,  viz.,  a  complete  and  perfect  drain- 
age of  the  uterine  interior.  The  patient  is,  we  will  sup- 
pose, cured  after  repetitions  of  tliis  process;  but  now  comes 
the  question,  How  much  of  the  cure  depends  on  the 
straightening  of  the  canal,  with  the  consequent  complete, 
if  only  temporary,  drainage  of  the  uterus,  and  how  much 
on  the  internal  cauterizatior.  ? 

One  method  of  answering  the  question  is  by  an  examina- 
tion of  the  results  of  treatment  limited  to  the  straightening 
of  the  uterine  canal.  It  is  the  fact  that  these  results  are  of 
the  most  satisfactory  kind,  and  they  undoubtedly  prove 
that  intra-uterine  medication,  so  much  insisted  on  as  neces- 
sary for  the  cure  of  endometritis,  is  not  required,  and  that 
the  supposed  good  effects  of  it  would  be  equally  witnessed 
after  more  simple  treatment. 

The  following  remarks  of  Dr.  Thomas  in  the  last  edition 
of  his  work  (1880)  on  applications  to  the  uterine  cavity  in 
cases  of  endometritis  may  here  be  quoted.  Dr.  Thomas 
says:  "  Enlarging  experience  during  the  past  five  years  has 
led  me  to  become  skeptical  as  to  the  utility  of  the  course. 
Observation  and  experience  have  so  changed  my  own  prac- 
tice that  I  find  myself  very  rarely  resorting  at  present  to 
applications  above  the  os  internum  uteri.  They  very  gen- 
erally fail  in  curing  the  disease,  and  they  are  by  no  means 
void  of  danger." 

And  with  regard  to  the  effect  of  the  "curette  treatm.ent 
for  fungosities,"  he  says,  "  in  a  great  man}' cases  he  has  had 
to  repeat  the  operation  of  scraping  about  once  a  year  for  a 
long  time"  (p.  349). 

Fungous  Conditio}!,  of  the  Lining  of  the  Uterus. — It  has  been 
found  in  many  cases  of  so-called  endometritis  that  the 
mucous  membrane  lining  the  body  of  the  uterus  has  pre- 
sented a  fungous  condition.  Under  such  circumstances 
there  frequently  occurs  profuse  losses  of  blood  at  the 
menstrual  period  and  saniouo  leucorrhoea  at  other  times. 
These  fungosities  have  been  frequently  removed  by  the 
curette,  and  the  roughened  surface  scraped  awa)',  thus 
removing  the  fungosities,  and  no  doubt,  in  many  instances, 


THE   LIXIXG   OF  THE   UTERUS.  I49 

with  results  which  have  been  found  encouraging  to  tlie  fur- 
ther prosecution  of  tliis  method  of  treatment. 

These  fungosities  appear  to  consist  essentially  of  the  mu- 
cous lining  of  the  uterus  in  a  swollen  hypertrophied  condi- 
tion, whereas  they  seem  to  have  been  treated  as  foreign 
bodies.  In  other  words,  they  do  not  appear  to  be  of  a  poly- 
poid character  or  to  resemble  those  growths  which  are  lia- 
ble to  be  met  with  in  the  interior  of  the  uterus,  ami  for  which 
actual  removal  is  the  proper  and  the  accepted  method  of 
treatment. 

A  short  time  since  a  case  came  under  my  notice  which 
enabled  me  to  make  an  observation  which  seems  to  have  an 
important  bearing  on  the  question  as  to  the  cause  and  na- 
ture of  the  condition  described  as  fungoid  excrescence  or 
growth  of  the  lining  membrane  of  the  uterus. 

The  subject  of  this  case  was  an  unmarried  lady,  42  years 
of  age.  Up  to  four  years  ago  she  had  had  moderately  good 
health,  though  never  strong.  At  that  time — four  years  ago 
— she  was  one  day  in  a  sailing-boat  on  the  sea  for  a  few 
hours.  She  became  violently  sick,  and  felt  something  give 
way  internally.  She  remained  ill  for  some  time,  after  being 
carried  ashore.  an<l  shortly  afterward  she  became  the  sub- 
ject of  severe  losses  of  blood  from  the  uterus.  She  was 
under  medical  treatment,  and  Dr.  Gooding  of  Cheltenham 
diagnosticated  anteversion  of  the  uterus,  for  relief  of  which 
a  pessary  was  employed.  Two  years  before  I  saw  her  she 
came  under  the  care  of  Dr.  Milner  Moore  of  Coventry,  still 
suffering  severely  from  haemorrhages;  after  some  little  time 
he  became  convinced  that  a  tumor  of  some  kind  occupied 
the  fundus  uteri.  She  improved  under  use  of  ergot,  and 
wearing  a  Thomas  pessary,  but  a  year  ago,  the  haemorrhage 
being  profuse,  and  the  uterus  considerably  enlarged,  he 
dilated  the  cervi.x,  and  found  a  growth  which  he  thought 
polypoid,  and  by  operation  he  removed  a  vascular  sarcoma- 
tous growth  from  a  broiid  space  at  the  right  portion  of  the 
fundus.  Strong  solution  of  perchloride  of  iron  was  applied. 
The  treatment  was  of  considerable  service  for  a  time,  but 
latterly  the  symptoms  had  recurred. 

On  March  16,  18S0,  I  saw  the  patient  at  Dr.  Moore's  re- 
quest. Dr.  Brockwell  of  Gipsy  Mill  assisting  me  in  the  man- 
agement of  the  case.  I  found  the  patient  excessively  weak 
and  much  emaciated.  She  complained  that  the  least  move- 
ment or  attempt  to  walk  brought  on  bleeding  and  pain. 
Her  appetite  was  gone  and  her  sleep  disturbed. 


ISO  DISEASES   OF  WOMEN. 

On  examination  I  found  tlie  uterus  acutely  anteflexed, 
much  congested,  and  the  fundus  the  size  of  a  cricket-ball, 
heavy,  and  tilted  forward  and  downward;  the  cervix  patu- 
lous and  the  tissues  of  the  organ  vascular  and  soft.  The 
sound  showed  the  uterus  to  be  elongated,  and  by  its  means 
the  organ  was  easily  bent  back  to  its  proper  shape,  but  it 
rather  quickly  resumed  the  anteflexed  shape  on  withdrawal 
of  the  sound. 

A  pessary  was  introduced  to  sustain  the  fundus  ante- 
riorly. In  a  day  or  two  the  uterus,  owing  to  its  great 
weight,  overcame  the  pessary  and  it  was  removed. 

On  March  19,  a  more  complete  examination  of  the  inte- 
rior of  the  uterus  was  made,  and  it  was  found  practicable 
to  pass  the  finger  quite  into  the  body  of  the  uterus,  the  tis- 
sues of  the  organ  being  so  relaxed.  It  was  found  that  the 
surface  of  the  body  of  the  uterus  presented  just  above  the 
internal  os  considerable  protruding  growths,  smooth,  soft 
excrescences,  the  lower  border  vevy  sharply  defined  at  the 
internal  os.  And  at  that  time  it  appeared  to  me  probable 
tliat  the  growths,  so  prominent  and  distinct,  were  really  of  a 
sarcomatous  nature.  This  being  the  opinion  arrived  at,  it 
was  decided  to  remove  them  b}^  operation. 

As  preparatory  to  the  operation,  the  patient  was  kept  on  her 
back.  And  every  day  the  fundus  was  directed  to  be  pushed 
up  by  the  finger,  and  the  anteversion  thus  as  far  as  possi- 
ble prevented,  with  the  view  of  facilitating  the  subsequent 
operative  procedure.  Dr.  Brockwell  carefully  carried  out 
these  manipulations. 

The  following  is  Dr.  Brockwell's  account:  "  On  March  20, 
the  day  following  your  visit,  the  uterus  was  large,  heavy, 
and  the  fundus  pressing  down  on  the  neck  of  bladder,  ten- 
der, and  seemed  to  be  wedged  in,  if  I  may  sa}"  so,  against 
the  OS  pubis.  I,  in  accordance  with  your  instructions, 
passed  the  first  and  second  fingers  up  to  the  fundus  and 
made  steady  pressure  for  some  minutes;  slowly,  and  after 
considera'^le  pressure,  the  organ  yielded  and  slipped  up 
into  position.  I  then  placed  the  patient  on  her  back,  with 
a  large  pillow  under  the  hips,  and  kept  her  there  till  next 
day,  when,  on  re-inserting  my  fingers,  I  found  the  uterus 
had  only  partially  returned;  it  yielded  much  more  easily 
tlian  the  day  before.  I  again  placed  the  patient  on  her 
back  as  before,  and  on  the  third  day,  although  a  little  for- 
ward, the  uterus  had  almost  entirely  lost  its  tenderness,  was 
very  much    smaller,   and  very  slight  pressure  sufficed.     I 


THE   LINING  OF  THE   UTERUS.  I5I 

Still  kept  her  on  the  back,  and  on  the  fourth  day  I  found 
the  organ  liad  retained  its  normal  position  and  continued 
to  do  so  till  you  came  for  the  operation  on  the  31st,  when, 
as  you  may  remember,  you  found  the  uterus  well  in  its 
place." 

The  proposed  operation  was  delayed  until  twelve  days 
later,  and  on  March  31  the  patient  was  placed  under  ether. 
On  now  examining  the  uterus  with  the  tinger  it  was  found 
that  the  interior  of  the  organ  had  undergone  a  very  remark- 
able change  during  the  twelve  days'  interval.  The  intu- 
mescence and  projecting  growths  seemed  to  have  almost 
disappeared — very  markedly  the  projection  just  above  the 
internal  os  had  disappeared — and,  in  fact,  there  seemed  to 
be  little  to  remove.  It  was  thought  advisable,  however,  to 
scrape  away  with  the  curette  the  slight  projection  still  re- 
maining, and  the  surface  was  touched  witlj  nitric  acid.  Dr. 
Brockwell  continued  to  maintain  the  uterus  in  its  proper 
place  by  occasional  pushing  up  of  the  fundus,  and  other  or- 
dinary measures,  careful  feeding,  and  use  of  injections, 
were  employed.  On  April  16  the  uterus  was  found  to  have 
returned  almost  to  its  proper  size;  the  fundus  was  in  fairly 
good  position,  and  a  cradle-pessary  (rather  large  size)  was 
inserted.  The  patient  was  wonderfully  better,  and  on  April 
27  she  was  able  to  travel. 

Remarks. — The  condition  of  the  patient  was  such  as  to 
give  the  impression  of  one  suffering  from  malignant  dis- 
ease; and  the  result  of  the  first  examinations  seemed  to 
justify  this  view.  The  remarkable  feature  in  the  case  was 
the  rapid  and  almost  complete  disappearance  of  the  growths 
from  the  interior  of  the  uterus  under  the  influence  of  rest, 
and  the  maintenance  of  the  uterus  in  a  proper  position. 
There  was  no  doubt  left  on  my  mind  that  the  supposed 
growths  were  merely  the  congested  hypertrophied  mucous 
membrane  of  the  uterus.  For  when  the  organ  was  so 
placed  that  its  circulation  became  less  embarrassed,  this 
congestion  and  swelling  subsided.  The  occurrence  of  se- 
vere bleeding  on  slight  exertion  was  abundantly  explained 
by  the  condition  of  the  mucous  membrane,  for  the  exertion, 
producing  greater  flexion  and  greater  obstruction  to  the 
circulation,  intensified  the  congestion  of  the  mucous  mem- 
brane. The  mere  resting  on  the  back  and  daily  elevation 
of  the  fundus  were  then  in  this  case  found  to  have  the  re- 
markable curative  effect  on  the  lining  of  the  uterus  above 
described. 


152  DISEASES   OF  WOMEN. 

There  is  no  doubt  that  the  condition  which  I  had  found 
to  be  present  resembled  that  observed  by  Dr.  Mihier  Moore 
a  year  previously.  The  great  emaciation,  the  great  irrita- 
tion, the  profuse  discharges,  and  the  considerable  tumor- 
like protrusions  felt  by  the  finger,  seemed  to  favor  the  no- 
tion of  a  sarcomatous  growth  in  the  interior  of  the  uterus. 
This  notion  was,  of  course,  dispelled  by  the  rapid  subsidence 
of  the  growth  which  took  place  under  observation. 

The  great  vascularit}'  of  the  lining  of  the  uterus,  which 
is  proved  to  be  ordinarily  present  during  or  just  before  men- 
struation, is  no  doubt  in  many  cases  intensified  under  vari- 
ous abnormal  conditions.  The  lining  of  the  uterus  then 
becomes  more  swollen  and  soft,  and  the  surface  becoming 
broken  down,  as  a  part  of  the  normal  process  of  menstrua- 
tion, the  mucous  membrane  presents  an  irregular,  villous, 
or  shaggy  aspect.  The  presence  of  such  villous  projections 
is  probably  indicative,  then,  not  of  new  growth,  or  indeed 
necessarily  of  any  abnormal  growth,  but  is  merely  the  re- 
sult of  extreme  congestion  of  this  mucous  membrane.  The 
condition  in  question  would  be  appropriately  termed  "con- 
gestive hypertrophy"  of  the  mucous  lining  of  the  body  of 
the  uterus. 

The  cause  of  the  congestion  which,  in  such  cases  as  the 
above,  determines  the  hypertrophy  of  the  mucous  mem- 
brane, may  be  different  in  different  cases.  In  this  particu- 
lar instance  the  congestion  seemed  to  be  produced  by  the 
distortion  of  the  organ.  The  acute  anteflexion  caused  an 
impediment  to  the  circulation,  and  hence  general  conges- 
tion, not  only  of  the  walls,  but  of  the  mucous  lining. 

It  is  a  matter  susceptible  of  easy  clinical  proof  that  the 
congested  uterus  is  relieved  by  being  placed  in  its  proper 
position,  and  b}'^  restoration  of  its  proper  shape.  I  have 
many  times  observed  this  occurrence,  but  I  never  before 
had  such  unmistakable  evidence  placed  before  me  of  the 
effect  of  these  mechanical  restorative  measures  in  reducing 
the  congestive  hypertrophy  of  the  lining  of  the  uterus. 

The  deductions  to  be  drawn  from  the  foregoing  consid- 
erations in  regard  to  the  treatment  of  cases  where  we  sus- 
pect or  know  of  the  existence  of  fungosities  of  the  uterine 
mucous  membrane  are  obvious. 

For  further  information  on  the  subject  of  the  pathology 
and  treatment  of  affections  of  the  lining  membrane  of  the 
uterus,  the  reader  is  referred  to  the  chapters  on  Leucor- 
rhoea  and  Menorrhagia. 


ACUTE   INFLAMMATION    OF   THE    UTERUS.  1 53 

CHAPTER  XI. 

Acute  Inflammation  of  the  Uterus. 
Nature  and  Treatment. 

Acute  inflammation  of  the  uterus  is  a  rare  event.  But  it 
is  alwaj-s  a  very  serious  one,  generally  dangerous,  and  fatal 
to  a  degree. 

Idiopatltically,  it  occurs  so  rarely  that  it  can  hardly  be  de- 
scribed, the  materials  being  wanting.  It  has  been  said  to 
occur  from  sudden  suppression  of  the  menstrual  flow;  but 
the  possibility  of  its  so  being  produced  is  doubtful,  the  cases 
thus  described  having  been  probably  accidental  effusion  of 
blood  into  the  peritoneal  cavity,  a  phenomenon  which  is 
liable  to  be  attended  with  very  severe  symptoms.  It  is 
also  stated  to  have  occurred  in  connection  with  gonorrhoea. 

Traumatically,  it  is  a  well-recognized  phenomenon. 
Wounds,  or  operations  on  the  cervix  or  os  uteri,  use  of 
tents  for  the  purpose  of  dilating  the  cervix  uteri,  the  in- 
cautious use  of  instruments  such  as  intra-uterine  pessaries, 
— these  are  the  causes  of  this  rare  but  serious  event. 

The  affection  appears  to  be  essentially  t)f  the  nature  of 
pyaemia,  attended  with  severe  pain,  a  well-defined  com- 
mencement, and  a  rapid  course.  There  is  almost  invariably 
evidence  of  the  absorption  by  the  internal  lining  of  the 
cervix  or  uterine  canal  of  certain  decomposing  materials, 
which  surface  has  been  previously  broken,  injured,  or 
bruised  at  some  point.  Its  symptoms  much  resemble  those 
of  puerperal  septicaemia. 

A  typical  case  occurs  as  follows:  Within  a  few  hours, 
sometimes  within  a  few  minutes,  of  the  time  of  the  absorp- 
tion of  the  irritating  agent  by  the  uterus,  the  patient  ex- 
periences an  acute  pain  in  the  hypogastrium,  concurrently 
with  which  she  e.xperiences  a  sharp  and  well-marked  rigor, 
and  a  feeling  of  unmistakable  and  profound  illness.  The 
pulse  instantly  rises  in  frequency,  running  up  in  a  few  hours 
to  120  or  130  in  the  minute,  the  temperature  also  quick- 
ly attains  a  great  height,  102°  to  103°  being  noted  within 
a  few  hours.  The  hypogastrium  is  acutely  sensitive  to  the 
touch  almost  from  the  beginning  ;  the  patient  lies  with  the 
knees  drawn  up,  and  shrinks  before  the  slightest  attempt 
to  explore  the  state  of  the  lower  part  of  the  abdomen. 
There  may  be  nausea  very  shortly,  or  the  nausea  may  be. 


154  DISEASES   OF   WOMEN. 

delayed  in  its  occurrence;  nausea  of  an  uncontrollable 
character  is  often  observed  the  following  day  and  persists 
until  the  fatal  termination.  The  vagina  becomes  very  hot 
to  the  touch,  the  uterus  itself  is  felt  swollen  and  sensitive 
to  an  extreme  degree.  Profuse  perspiration,  generally 
given  as  a  symptom  of  pyaemia,  has  not  been  present  in  the 
cases  of  acute  inflammation  of  the  uterus  which  I  have  ob- 
served. 

The  further  progress  of  the  disease  is  marked  by  increase 
of  frequency  of  pulse,  temperature  running  up  to  103°  or 
even  107°,  continued  prostration,  extension  of  the  inflam- 
mation (generally)  to  the  peritoneum,  hurried  respiration, 
great  weakness  of  the  pulse,  and  death,  or  passing  of  the 
disease  into  a  less  acute  stage,  and,  possibly,  the  beginning 
of  recovery. 

The  septicaemia  thus  occurring  is  perhaps  the  most  rapid 
in  its  course  of  any  of  the  known  forms  of  this  affection, 
probably  owing  to  the  great  vascularit}^  of  the  uterus,  and 
the  great  rapidity  witli  which  absorption  from  its  interior 
is  liable  to  occur. 

The  pathological  appearances  after  death  are  usually  un- 
due size  and  softness  of  the  uterine  tissues,  and  evidence  of 
peritonitis  on  the  external  part  of  the  organ,  effusion  of 
lymph  and  puriform  fluid  in  the  abdomen.  In  the  uterine 
tissues  themselves  there  may  be  little  evidence  of  change. 

Treatment. — The  early  administration  of  powerful  stimu- 
lants, such  as  quinine,  ether,  alcohol,  appears  the  best  treat- 
ment to  follow  in  a  given  case.  These  remedies  must  be 
given  in  large  doses.  Tincture  of  iron  is  probably  also 
serviceable.  Copious  injections  of  hot  water  slightly  car- 
bolized  should  be  given  by  the  vagina.  It  appears  to  me 
probable  that  electricity,  by  which  the  contractions  of  the 
uterus  could  be  excited,  would  be  beneficial.  A  large  lin- 
seed poultice  with  laudanum  should  be  applied  to  the  hypo- 
gastric region. 

In  cases  of  septic  peritonitis  following  ovariotomy  the 
lowering  of  the  temperature  by  cold  affusions  to  the  head 
by  means  of  the  ice-bag,  has  proved  in  some  cases  of  great 
service.  There  seems  no  reason  why  the  same  treatment 
should  not  be  applied  to  the  cases  now  under  consider- 
^tion. 


DEFECTIVE   DEVELOPMENT   OF  THE   UTERUS.      1 55 


CHAPTER  XII. 

Defective  Development  of  the  Uterus — Congenital 
Malformations. 
Diagnosis. 
List  ok  Cases. — Absence  of  Rudirricntary  Formations  of  the  Uterus — 

Infantile  Uterus — Uterus  Unicornis — Double  Uterus — Absence  of  the 

Os  Uteri. 

Diagnosis. — The  diagnosis  of  the  various  forms  of  irregu- 
larity of  development  of  the  uterus  is  important.  Asso- 
ciated as  these  defects  usually  are  with  alterations  or  de- 
fects in  the  formation  of  the  vagina,  it  is  convenient  to 
consider  their  diagnosis  together.  In  the  chapter  on  Dis- 
eases of  the  Vagina  detailed  directions  for  such  investiga- 
tion will  be  found. 

At  University  College  Hospital,  in  a  period  of  about  five 
years,  six  cases  of  congenital  malformation  occurred  out  of 
about  1,200  cases.  The  absolute  frequency  of  these  mal- 
formations is  of  course  not  to  be  gathered  from  these  statis- 
tics, as  the  conditions  might  have  existed  in  other  instances 
not  examined. 

Abstract  Account  of  Cases  of  Imperfect  Development  of  Uterus. 
University  College  Hospital. 


Age. 

Initials. 

fc.S 
nt/3 

u 

Remarks. 

18 

L.J 

s. 

— 

A  very  slight  show  at  aet.  15  for  i  day. 
Nothing  since.  Uterus  small.  Half  an 
inch  too  short.     Molimen  slight. 

i\ 

E.J 

s. 

— 

No  menstruation.     Uterus  measures  i  inch 

22 

E.  H 

M. 

— 

only  in  length. 
No  menstruation.      Uterus  a  little    shorter 
than  normal.      Has  a  sister  in  same  state. 

26 

E.  J.  B... 

M. 

0 

Married  2  years.  Menstruation  almost  nil. 
A  spot  or  two  occasionally.  Uterus 
appears  to  have  a  double  cavity,  but  a 
single  OS. 

28 

Mrs.  D... 

M. 

0 

Married  4  years.     No   catamenia.     Uterus 

30 

M.  W 

S. 

only  half  an  inch  long. 
No  menstruation.     No  evidence  of  action  of 
ovaries.      Uterus  size  of  a  pea.     Vagina 
half  natural  length.     Breasts  undeveloped. 
Cords  can  be    felt  in  situation    of  Fallo- 
pian tubes /i-r  rectum. 

156 


DISEASES    OF   ^YOiMEN. 


The  following  are  the  chief  varieties  of  defective  develop- 
ment of  the  uterus: 


ABSENCE    OR    RUDIMENTARY    FORMATION    OF    THE    UTERUS. 

Cases  of  entire  absence  of  the  uterus  are  of  extreme 
rarity,  and  there  are  good  reasons  for  believing  that  when 
apparently  absent  the  organ  is  yet  represented  by  imperfect 
yet — to  the  anatomist — recognizable  traces  of  a  structure 
having  the  outline  and  general  arrangement  of  the  uterus. 
The  ovaries — the  essential  portions  of  the  female  generative 
organs — are  observed  to  be  present  in  cases  where  the  uterus 
is  represented  by  mere  traces  of  muscular  fibres  and  cellular 
tissue  only.     A  type  of  the  condition  here  alluded  to  is  a 


Fig.  27. 


case  recorded  by  Rokitansky,*  in  which  the  vagina  con- 
sisted of  a  fossa  one  inch  long,  the  uterus  represented  by 
muscular  fibres  arranged  in  the  form  of  the  uterus,  the 
Fallopian  tubes  more  decidedly  pronounced  and  presenting 
each  a  small  cavity,  the  ovaries  present  (Fig.  27). 

The  particular  part  of  the  uterus  formed  ma}'  be  limited 
chiefly  to  the  cervix,  to  the  upper  part,  or  to  one  side. 

Absence  or  rudimentary  formation  of  the  uterus  may  be 
associated  with  complete  absence  of  the  vagina,  or  with 
rudimentary  formation  of  this  canal.  With  respect  to  the 
condition  of  the  vagina  in  such  cases,  the  following  is  an 
illustrative  fact:  I  had  occasion  a  few  years  since  to  examine 

*  See  Kussmaul's  valuable  work,  "Von  dem  Mangel,  der  Verkiim- 
merung  und  Verdopplung  der  Gebarmutter,"  Wurzburg,  1859,  p.  20. 


DEFECTIVE  DEVELOPMENT  OF  THE  UTERUS.   1 57 

a  lady  aet.  20,  presenting  the  following  conditions;  puden- 
dum covered  with  hair,  labia  majora  well  developed,  vagina 
represented  by  a  mere  little  pit  admitting  the  uterine  sound 
only  half  an  inch,  no  uterus  or  hard  body  to  be  discovered 
between  the  bladder  and  rectum  high  up.  Signs  of  ovarian 
activity  had  been  observed  on  two  or  three  occasions,  giving 
reasons  for  the  belief  th^  the  ovaries  were  present.  The 
breasts  were  well  developed. 

INFANTILE    UTERUS. 

Under  this  term  are  included  those  cases  in  which  the 
uterus  is  regularly  formed,  and,  so  far,  complete  in  its  parts, 
but  where  it  retains  during  adult  age  the  size  the  uterus 
ordinarily  possesses  during  early  childhood,  or  prior  to  the 
event  of  puberty.  At  the  age  when  the  arrival  of  puberty 
is  generally  witnessed,  the  growth  of  the  uterus  proceeds 
rapidly,  the  dimensions  which  it  then  acquires  being  those 
which,  with  certain  exceptions,  it  retains  until  the  end  of 
what  may  be  termed  sexual  life.  But  in  a  few  instances, 
when  the  age  of  puberty  arrives,  the  uterus  fails  to  develop, 
and  retains  its  child-like  size  far  beyond  the  customary 
period.  In  such  cases  menstruation  does  not  usually  occur, 
although  the  patient  may  present  signs  of  ovarian  functional 
activity.  Various  degrees  of  this  defective  development  of 
the  uterus  are  observed,  all,  however,  associated  with  one 
symptom,  viz.,  amenorrhcea  or  imperfect  menstruation.  In 
some  instances  the  condition  primarily  at  fault  is  congeni- 
tal, while  in  others  it  appears  to  be  connected  with  mal- 
nutrition at  the  critical  period  of  the  arrival  of  puberty. 

A  sufficiently  typical  instance  of  the  infantile  uterus  is 
that  of  a  young  woman  who  was  under  my  care  at  Uni- 
versity College  Hospital.  Her  age  was  22;  she  had  never 
menstruated,  the  external  generative  organs  and  the  breasts 
well  developed,  the  uterus  slender,  two  inches  long  as 
measured  by  the  uterine  sound,  the  vaginal  portion  of  the 
cervi.x  slight,  the  os  uteri  exceedingly  small.  This  patient 
began  to  suffer  from  symptoms  indicative  of  ovarian  activity 
at  the  age  of  sixteen,  but  menstruation  had  never  actually 
occurred.  Several  cases  of  infantile  uterus  will  be  found 
recorded  in  Kussmaul's  work.  Very  numerous  variations 
are  met  with.  Thus  the  body  of  the  uterus  may  be  im- 
perforate, or  the  uterus  may  have  two  cornua  instead  of 
being  a  single  organ,  or  the  imperfect  development  may 
only  exist  us  regards  the  cervical  portion. 


158  DISEASES  OF  WOMEN. 

Further,  the  history  of  certain  recorded  cases  renders  it 
evident  that  the  infantile  uterus  may  undergo  at  a  very  late 
period  the  ordinary  development,  and  also  that,  although 
in  by  far  the  majority  of  cases  the  subjects  of  this  condition 
are  destitute  of  the  power  of  conception,  yet  that  the  con- 
trary may  be  observed.  The  breasts  are  generally  small; 
the  external  generative  organs,  the  labia,  clitoris,  and 
vagina,  also  smaller  than  usual;  the  pudendum  is,  as  a 
rule,  imperfectly  covered  with  hair.  The  individual,  as  a 
rule,  is  stunted  as  regards  size  and  development  of  the  body 
generall}'',  but  by  no  means  always  so.  The  ovaries  have 
been  found  quite  absent,  but  this  is  generally  not  the  case; 

Fig.  28. 


the  ovaries  also  contain  Graafian  follicles,  and  the  men- 
strual molima  are  more  or  less  well  marked,  although  the 
menstrual  discharge  is  almost  always  entirely  absent.  Sex- 
ual desire  is  frequently,  but  not  always,  found  wanting.* 

UTERUS    UNICORNIS. 

Under  this  term  are  included  those  cases  in  which  the 
uterus  presents  a  division  superiorly  into  two  parts  or  cor- 
nua,  one  of  which  is  more  developed  and  larger  than  the 
other.  There  are  several  varieties  in  reference  to  the  rela- 
tive size  of  the  two  cornua  in  different  cases,  and  obviously 
when  the  two  cornua  are  nearly  alike  in  point  of  size  the 
term  "unicornis"  is  not  applicable.     In  Kussmaul's  cele- 

*  Kussmaul,  op.  cil.  p.  94. 


DEFECTIVE  DEVELOPMENT   OF  THE    UTERUS.      1 59 

brated  work  all  these  varieties  will  be  found  described  to- 
gether with  various  exceedingly  interesting  facts  relative 
to  the  history  of  pregnancy  under  these  unusual  circum- 
stances. The  second  cornu  is  always  present,  although  it 
may  be  exceedingly  small.  A  typical  case  of  the  uterus 
unicornis  is  that  recorded  by  Pole.*  (See  Fig.  28.  The 
uterus  is  here  seen  from  behind.) 

DOUBLE    UTERUS. 

The  several  varieties  of  the  double  or  bipartite  uterus  are, 
as  is  the  case  in  other  instances  of  malformation,  traceable 


Fig.  29. 


to  arrest  of  development  in  early  foetal  life,  and  with 
•  eference  to  all  of  them  it  may  be  said  that  they  represent 
what  is  a  normal  and  persistent  condition  of  the  uterus  in 
inferior  orders  of  mammalia. 

A  most  complete  separation  of  the  two  parts  of  the  uterus 
is  sometimes  witnessed,  each  side  representing  a  separate 
cavity  opening  below  by  a  separate  orifice  into  a  distinct 
and  separate  vagina,  each  vagina  presenting  externally  a 
distinct  orifice.     This  condition  is  very  rare. 

The   next   variety — the  uterus    duplex  bicornis — is   well 


*  "  Memoirs  of  Med.  Soc.  of  Lond.,"  1794,  p.  507,  and  Kussmaul,  o^, 
cit.  p.  22. 


i6o 


DISEASES   OF  WOMEN. 


illustrated  by  a  case  recorded  by  Schroeder*  (see  Fig.  29). 
The  two  halves  of  the  uterus  are  here — externally — con- 
nected, but  the  two  cavities  are  completely  distinct. 

Here  it  may  be  stated  that  the  division  between  the  pro- 
per cavity  of  the  uterus  and  the  Fallopian  tube  is  always 
decided  by  the  position  of  the  round  ligament.  Unless  this 
be  attended  to,  there  would  be  a  liability  of  confounding 
the  uterus  bicornis  with  the  more  completely  and  distinctly 
double  uterus. 

Fig.  30. 


Following  Kussmaul's  arrangement,  another  variety  is 
that  in  which  the  uterus  appears  externally  of  the  normal 
form,  the  cavity  being,  however,  completely  divided  into 
two  by  a  septum  running  down  the  middle.  This  Kuss- 
maul  terms  the  "uterus  duplex  omnino  conjunctus  vel  u. 
septus."  Rokitansky's  "uterus  bilocularis"  (Fig.  30)  is 
from  a  case  of  Liepmann's,f  and  was  taken  from  a  girl  set. 

*  From  Kussmaul,  p.  25.  In  the  same  work,  p.  197,  will  be  found  a 
drawing  from  a  case  of  Carus,  in  which  one  uterus  is  occupied  by  a 
fcEtus. 

f  See  Kussmaul,  op.  cit.  p.  26. 


DISPLACEMENTS,   t)ISTORTIONS   OF  THE   UTERUS.    l6l 

19.  The  vagina  was  in  this  case  double,  as  also  the  uterus, 
although  tiiere  is  no  indication  of  this  externally.  The 
vaginal  canals  are  laid  open  from  behind. 

There  are  yet  further  modifications.  Thus,  the  septum 
between  the  two  sides  of  the  uterus  may  only  extend  half 
way  down  the  uterus,  in  which  case  there  is  only  one  os 
uteri,  while  the  cavity  superiorly  is  double  ("uterus  sub- 
septus"),  or  again  the  uterus  may  be  single  at  the  cervix, 
and  completely  double  above  that  point,  constituting  the 
''uterus  bicornis  unicollis."  Instances  of  these  two  vari- 
eties are  given  by  Kussmaul. 

Lastly,  a  case  of  Eisenmann's  may  be  referred  to  which 
stands,  as  Kussmaul  remarks,  midway  between  the  uterus 
bicornis  and  the  uterus  septus:  here  the  uterus  is  distinctly 
double,  as  also  the  vagina,  the  two  uteri  are  quite  parallel, 
and  the  two  cavities  long  and  narrow.  A  groove  marks 
externally  the  division  between  them. 

Some  remarks  on  the  treatment  of  cases  of  imperfect  de- 
velopment of  the  uterus  will  be  found  in  the  chapter  on 
Amenorrhoea. 

ABSENCE    OF    ORIFICE    OF    OS    UTERI. 

This  is  another  congenital  malformation  which  is  met 
with  but  rarely.  The  aperture  at  the  lower  extremity  of 
the  cervix  uteri  (os  uteri  externum)  may  be  absent,  or  the 
canal  may  be  imperforate  higher  up.  In  either  case  there 
may  occur  an  accumulation  of  menstrual  fluid  when  puberty 
arrives.  This  condition  may  be  associated  or  not  with  an 
imperforate  vagina  or  with  absence  of  the  latter  canal. 


CHAPTER   XIII. 


Displacements,  Distortions  (Flexions),  of  the  Uterus 
— I.  Normal  Shape,  Position,  and  Movements  of  the 
Uterus. 

Normal  Shape,  Position,  and  Movements  of  the  Uterus. — Form 
and  Shape,  how  preserved  in  a  State  of  Health — The  Proper  Position 
of  the  Uterus:  Discussion  of  various  Opinions  on  the  Subject:  Schultze, 
Schroeder,  De  Warker,  etc. — Conclusion  arrived  at — Normal  Move- 
ments of  the  Uterus — Degree  of  Fixation    of  the  Uterus — Motions  de- 


l6i  DISEASES   OF  WOMEN. 

scribed:  i,  Descent;  2,  Rotation  on  Transverse  Axis;  3,  Flexion — Effect 
of  Evacuation  of  Contents  of  Bladder  considered. 

THE    NORMAL    SHAPE    OF    THE    UTERUS. 

The  Uterus  maybe  said  to  consist  of  two  parts:  the  body, 
or  uterus  proper,  and  the  cervix;  the  general  shape  of  the 
organ  being  somewhat  that  of  a  pear.  The  body  of  the 
uterus  is  a  little  less  rounded  posteriorly  than  anteriorly. 
The  junction  between  the  body  of  the  uterus  and  the  cervix 
is  not  indicated  by  the  external  outline.  The  width  of  the 
body  of  the  uterus  is  greater  than  its  antero-posterior 
measurement,  one  result  of  which  is  that  the  cavity  of  the 
uterus  proper  has  a  somewhat  triangular  shape.  The  thick- 
ness of  the  walls  of  the  body  and  of  the  cervix  are,  when  the 
uterus  is  unimpregnated,  and  in  a  state  of  health,  such  that 
the  cubical  space  comprised  by  its  cavities  is  very  small, 
the  body  of  the  uterus  presenting  a  cavity  wide  from  side 
to  side,  but  with  its  anterior  wall  almost  in  contact  with 
the  posterior,  and  the  cervical  cavit}'  being  a  tube,  somewhat 
fusiform  in  shape,  becoming  narrow  above  where  it  opens 
into  the  uterine  cavity  proper  (internal  os  uteri),  and  nar- 
row also  below  where  it  constitutes  the  external  os  uteri. 

The  general  shape  of  the  uterus  is  pyriform,  as  already 
stated,  but  it  is  generally  considered  that  in  its  normal 
healthy  state  the  axis  of  the  uterus  is  not  quite  straight, 
but  that  it  is  a  little  bent,  so  as  to  present  a  slight  concav- 
ity on  its  anterior  aspect.  This  is  what  is  termed  the  natu- 
ral anterior  curvature  of  the  uterus.  It  appears  that  before 
puberty  this  anterior  curvature  is  more  decidedly  marked, 
but  that  when  puberty  arrives  and  the  uterus  undergoes  its 
full  development,  the  anterior  curvature  is,  in  part  at  least, 
lost.  It  seems,  further,  certain  that  in  some  few  cases  the 
pre-pubertal  degree  of  anterior  curvature  is  continued  for 
a  longer  time  than  usual,  especially  when  circumstances 
are  adverse  to  healthy  development  and  growth  of  the  body 
generallv.  The  presence  of  slight  anterior  curvature  after 
puberty  has  been  reached  is  a  matter  of  considerable  im- 
portance in  discussion  of  the  question  as  to  how  far  ante- 
flexion of  the  uterus  is  a  disease  or  not,  and  it  has  over  and 
over  again  been  used  as  an  argument  on  the  negative  side. 
A  correct  understanding  on  this  subject  is  therefore  im- 
portant. There  is  no  doubt  in  my  own  mind  that  a  slight 
anterior  curvature  is  normal,  when  the  uterus  has  reached 
its  full  healthy  development.     It  is,  however,  as  absurd  and 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    163 

illogical  as  it  appears  unpractical  to  assume  that  a  slight 
anterior  curvature  of  the  uterus  is  normal,  no  excess  in  the 
degree  of  anterior  curvature  can  be  abnormal;  and  yet  the 
argument  has  been  strained  to  even  this  extent. 

In  Fig.  31  is  represented  what  I  consider  to  be  the  nor- 
mal degree  of  anterior  curvature  in  the  multiparous  uterus, 
the  patient  being  supposed  to  be  in  the  standing  position. 

It  cannot  for  a  moment  be  doubted  that  in  a  state  of 
health  the  uterus  has  a  certain  standard  of  form,  departures 
from  which  are  to  be  regarded  as  abnormal.  The  various  or- 
gans of  the  human  body  havethe  form  and  structure  assigned 
to  them  which  are  designed  to  adapt  them  to  their  several 
uses.  It  would  be  strange  if  the  uterus  were  an  exception 
to  this.  A  priori  reasoning  alone  would  lead  us  to  the  con- 
clusion that  the  uterus  is,  when  possessed  of  its  natural 
form,  better  adapted  for  its  purposes  than  when  distorted; 
as  a  matter  of  fact  clinical  experience  shows  that  when  it 
has  lost  its  natural  form  grave  inconveniences,  disturbance 
of  important  functions,  dysmenorrlioea,  sterility,  etc.,  gen- 
erally result. 

It  is  necessary  to  consider  for  a  moment  the  arrange- 
ments nature  has  provided  for  the  preservation  of  the  form 
of  the  uterus.  The  most  important  of  these  is  the  rigidity 
of  the  uterus  itself,  a  quality  conferred  upon  it  by  the  den- 
sity of  its  structure.  When  the  unimpregnated  uterus  is 
in  a  state  of  health  it  may  be  practically  considered  as  an 
almost  solid  body,  for  the  cavities  within  are  small  and  de- 
tract little  from  its  solidity.  "The  inherent  strength  and 
resistance  of  the  proper  tissue  of  the  organ"  are,  as  Dr. 
Thomas  remarks,  the  chief  safeguard  against  bending  of 
tlie  uterus.  The  tissues  of  the  uterus  have  naturally  a 
hardness  and  firmness  much  greater  than  that  of  ordinary 
muscle.  It  is  this  hardness  and  firmness  which  secure  the 
permanency  of  the  shape  of  the  uterus.  The  uterus  in  a 
state  of  health  may  be  likened  to  a  solid  pear-shaped  mass 
of  india-rubber,  which  preserves  its  shape  by  reason  of  its 
solidity,  and  which  returns  to  its  shape  when  slightly  bent 
by  reason  of  its  elasticity.  But  the  pliability  is  not  so  great 
as  in  the  case  of  india-rubber,  nor  is  the  elasticity  so  con- 
siderable. These  considerations  are  very  important  in 
reference  to  the  causation  of  flexions.  In  a  former  chapter 
abnormal  softness  of  the  uterus  has  been  described  as  a 
pathological  condition;  the  foregoing  considerations  render 
it  evident  how  softness  of  the  uterine  walls  would  takeaway 


164  DISEASES  OF  WOMEN. 

from  the  uterus  that  rigidity  and  firmness  on  which  it  has 
to  rely  for  the  preservation  of  its  natural  form  and  shape. 
It  does  not  appear  that  the  attachments  and  ligaments  of 
the  uterus  aid  materially  in  maintaining  its  proper  shape, 
though  of  course  they  affect  its  position.  The  chief  attach- 
ments of  the  uterus  are  at  the  middle  portion,  the  two  ex- 
tremities of  the  organ  being  left  comparatively  free.  The 
attachments  of  the  uterus  are  indeed  such  that  they  rather 
detract  from  than  add  to  its  rigidity,  and  they  do  not  cer- 
tainly materially  increase  its  rigidity  as  a  whole.  The  axis 
of  suspension  of  the  uterus  is  a  straight  line  passing  trans- 
versely across  the  middle  of  the  organ.  The  two  poles  of 
the  uterus  are  free  to  move  as  compared  with  the  central 
portion;  and  the  condition  of  the  fundus,  poised  as  it  were, 
and  free  from  anterior  or  posterior  attachment,  gives  it 
an  instability  which  is  not  favorable  to  the  preservation  of 
the  proper  shape.  Tlie  same  holds  good  in  reference  to 
the  vaginal  portion  of  the  cervix,  which  presents  a  conical 
protuberance  into  the  vaginal  canal  and  is  likewise  free 
and  likely  to  be  acted  on  by  disturbing  mechanical  agencies. 

NORMAL    POSITION    OF    THE    UTERUS. 

Many  disputed  questions  hinge  on  the  determination  of 
what  is  the  normal  position  of  the  uterus.  It  might  be 
considered  that  it  is  easy  to  determine  this  elementary 
point,  but  nevertheless  it  is  one  on  which  there  are  grave  dif- 
ferences of  opinion.  In  an  exhaustive  essay  "  On  the  Normal 
Position  and  Movements  of  the  Unimpregnated  Uterus,"  by 
Dr.  Ely  Van  de  Warker,*  the  subject  has  been  recently 
discussed  and  a  rc'sianc  given  of  the  opinions  of  various 
authorities  on  the  subject.  In  Germany,  particularly,  Kohl- 
rausch,  Braune,  Schroeder,  Schultze,  and  Martin  have  ex- 
pressed views  on  the  subject  of  a  conflicting  character. 

Dr. Van  de  Warker,  rightly,  it  seems  to  me,  afhrms  that  the 
actual  position  of  the  organ  in  the  living  must  be  studied 
in  the  living.  If  post-mortem  sections  are  appealed  to  great 
care  should  be  taken  to  avoid  sources  of  error.  An  instance 
of  the  necessity  for  this  caution  is  afforded  by  the  Atlas  of 
Braune,  in  which  the  section  of  a  frozen  subject  (a  young 
woman)  is  given,  and  shows  the  position  of  the  uterus  (in 
the  early  gravid  state)  in  the  pelvis.  On  first  looking  at 
the  plate  it  appeared  to  me  that  the  lower  part  of  the  uterus 

*  "American  Journal  of  Obstetrics,"  vol.  xi.  p.  314. 


DISPLACEMENTS,   DISTORTIONS  OP  THE   UTERUS.    165 

was  represented  unusually  low  down  in  the  pelvMS,  and  on 
referring  to  the  text  I  found  it  stated  that  the  subject  in 
question  was  a  woman  who  had  died  from  hanging.  The 
mode  of  death  was  evidently  the  cause  of  the  extremely  low 

Fig.  31. 


position  of  the  os  uteri,  of  the  urethra,  and  of  the  vaginal 
aperture.  And  yet  this  plate  has  apparently  been  taken  by 
some  authorities  as  a  guide  to  the  normal  position  of  the 
uterus.  Schroeder  appears  to  have  been  influenced  by  this 
particular  plate,  for  a  line  drawn  from  the  under  part  of  the 


l66  DISEASES  OF  WOMEN* 

pubes  to  the  tip  of  the  coccyx  passes  through  the  Uterine 
cervix  in  tiie  drawing  which  he  gives  as  representing  the 
normal  position  of  tlie  uterus.  Schultze  criticises  this  posi- 
tion, and  Schroeder  defends  it  by  appealing  to  Braune  as 
an  authority! 

As  regards  the  proper  position  of  the  uterus,  there  are 
two  questions  to  be  decided — one  as  to  the  position  of  the 
uterus  in  the  pelvis  in  relation  to  the  brim  and  outlet;  the 
other  as  to  its  relation  to  the  anterior  and  posterior  walls 
of  the  pelvis. 

The  idea  that  I  have  been  led  to  form  from  actual  obser- 
vation is  that  under  normal  circumstances  the  uterus  occu- 
pies a  nearly  median  position  in  the  pelvis — that  is  to  say, 
that  the  top  of  the  fundus  either  corresponds  to  or  is  just 
below  the  plane  of  the  brim,  and  that  the  os  uteri  is  just  a 
little  above  the  plane  of  the  outlet  (pubo-coccygeal  line); 
also  that  it  is  placed  in  the  pelvis  about  equidistant  from 
the  pubic  bones  and  the  middle  of  the  sacrum.  The  posi- 
tion of  the  uterus  as  just  described  corresponds  to  what  is 
termed  the  curve  of  Cams,  and  it  appears  to  me  that  the 
uterus  does  in  a  state  of  health  occupy  this  position,  sub- 
ject to  certain  disturbances  which  will  be  presently  alluded 
to  in  connection  with  the  question  as  to  the  natural  move- 
ments of  the  uterus.  Reference  to  the  accompanying  draw- 
ing (life-size),  which  represents  what  I  consider  to  be  the 
typical  position  of  the  os  uteri  on  a  sectional  lateral  view, 
will  render  this  statement  intelligible.  The  drawing  has 
been  carefully  made  on  the  basis  of  one  by  Kohlrausch,  but 
in  some  respects  a  little  altered  from  this  author's  figure. 

In  the  drawing  (Fig.31)  the  bladder  is  represented  as  being 
full.  It  is  probable  that  when  the  bladder  is  empty  the 
upper  part  or  body  of  the  uterus  is  a  little  nearer  the  pubes 
than  as  above  shown.  This  point  will  be  presently  further 
enlarged  upon. 

The  above  view  as  to  the  normal  position  of  the  uterus  is 
not  the  one  entertained  by  Schultze  or  Schroeder,  or  Van  de 
Warker.  Schroeder  places  the  uterus  as  a  whole  lower  in 
the  pelvis.  Schultze  places  the  os  uteri  in  about  the  same 
position,  but  gives  the  body  of  the  uterus  a  much  greater  in- 
clination forward.  Van  de  Warker  simply  adopts  Schultze's 
view  of  the  subject.  Schultze,  followed  by  Van  de  Warker, 
contends  that  the  uterine  body  becomes  anteverted  as  the 
bladder  is  emptied  (Fig.  32),  and  assumes  a  more  upright 
position  when  it  is  full.     Such  is  not  the  conclusion  my  ob- 


DISPLACEMENTS,   DISTORTIONS   OF  THE   iJTfeRUS.    167 

servations  have  led  me  to  form.  It  appears  to  me  that  tlie 
space  created  between  the  uterine  body  and  the  symphysis 
pubis  by  the  evacuation  of  the  bladder  is  normally  fdled  by 
the  descent  of  the  intestines  upon  the  bladder,  and  that  the 
uterus,  when  in  a  state  of  health,  remains,  as  a  rule,  com- 
paratively unaffected  by  emptying;  the  bladder.  Schultze's 
experiment  on  livinor  subjects  appeared  to  him  to  show  that 
when  the  bladder  is  empty  the  uterus  follows  it,  but  we 
have  no  proof  tliat  the  experiments  were  performed  on  sub- 
jects really  in  a  state  of  health,  and  they  are  opposed  to  the 
results  of  my  own  observations.  Martin  expresses  his  opin- 
ion as  adverse  to  that  of  Schultze  also  in  respect  to  this  sup- 
posed version  of  the  uterus  on  emptying  the  bladder.  The 
notion  of  anteversion  being  natural  is  favored  by  the  cir- 
cumstance that  there  is  a  slight  natural  anterior  curvature. 
It  is  also  favored  by  the  circumstance  that  what  I  should 
term  <rA//<v-///<7/ anteversion  and  flexion  are  common,  as  will 
be  by-and-by  explained.  My  own  observations  have  led  me 
to  the  conclusion  that  when  the  body  of  the  uterus  persist- 
ently occupies  a  position  such  as  would  be  considered 
natural  by  certain  of  the  authorities  above  cited,  symptoms 
of  a  troul)lesome  character  are  always  observed  and  in- 
dicate the  abnormality  of  the  position  the  uterus  occupies. 
In  conclusion,  after  comparing  various  opinions  and  test- 
ing them  by  the  results  of  personal  observation,  my  opinion 
is  that,  in  a  state  of  health,  the  unimpregnated  uterus  has  a 
nearly  median  position  in  the  pelvis;  that  it  is  incorrect  to 
imagine  that  the  fundus,  in  a  state  of  health,  encroaches 
materially  on  the  space  devoted  to  the  bladder;  and  that  it 
is  incorrect  to  suppose  that,  in  a  state  of  health,  the  os  uteri 
is  so  low  down  as  to  rest  on  the  floor  of  the  pelvis. 

THE  NORMAL  MOVEMENTS  OF  THE  UTERUS. 

The  uterus  is  suspended  in  the  pelvis  by  the  various  liga- 
ments and  attachments  already  descril^ed.  If  we  imagine  a 
line  drawn  horizontally  from  side  to  side,  passing  through 
the  middle  of  the  uterus,  this  would  represent  what  has 
been  termed  the  axis  of  suspension  of  the  uterus.  This  axis 
of  suspension  is  not  rigid;  but  in  health  the  uterus  has  a 
tendency  to  come  back  to  this  position  when  removed  from 
it.  The  effect  is,  that  the  upper  part  of  the  uterus,  as  well 
as  its  lower  part,  is  more  movable  than  the  centre.  A  rota- 
tory movement  to  a  limited  extent,  backward  or  forward, 
may  be  readily  made  on  this  imaginary  axis  of  suspension, 


l6S  DISEASES    OF   WOMEN. 

and  when  we  come  to  examine  the  ^i^normal  movements  of 
the  uterus,  this  rotatory  motion  will  be  shown  to  be  a  very 
important  element  in  the  consideration.* 

The  fixature  of  the  uterus  is  such  that  a  certain  degree 
of  freedom  of  movement  is  allowed,  and  there  can  be  no 
doubt  that  within  this  range  movement  does  habitually 
occur.  We  have  now  to  determine  what  this  normal  range 
of  movement  is.  The  ligaments  and  attachments  of  the 
uterus  limit  its  motion.  Anteriorly  the  uterus  has  attach- 
ments of  an  extensive  character  to  the  bladder,  and  through 
the  bladder  and  its  peritoneal  investment,  to  the  abdominal 
wall  in  front;  this  attachment  is  such  that  it  generalh'  pre- 
vents the  uterus  as  a  whole  from  moving  directly  backward: 
if  the  bladder  be  much  distended  it  is  at  first  pushed  back- 
ward, and  if  the  distension  become  still  greater  a  tilting  of 
the  body  of  the  uterus  backward  results. 

Behind  the  uterus  we  find  the  sacro-uterine  ligaments, 
one  on  each  side,  near  the  middle  line.  These  vary  very 
much  in  strength  in  different  cases,  according  to  my  obser- 
vation. In  some  cases  they  are  hardly  recognizable  by  the 
touch.  In  others  they  are  firm  bands.  They  tend  to  pre- 
vent motion  of  the  middle  part  of  the  uterus  forward,  and 
together  with  the  utero-vesico-pubic  attachments  they  secure 
for  the  uterus  a  median  position  between  the  sacrum  and 
the  pubic  bones.  But  they  do  not  affect  the  fundus  uteri 
or  the  OS  uteri  except  in  an  indirect  manner.  The  utero- 
sacral  ligaments  control  also  descent  of  the  uterus,  and  tend 
to  prevent  the  uterus  as  a  whole  from  moving  down  on  to 
the  floor  of  the  pelvis  or  toward  the  vaginal  aperture. 

The  broad  ligaments  of  the  uterus,  including  the  cellular 
tissue  enclosed  in  their  layers  and  surrounding  the  plexus 

*On  this  subject  reference  may  again  be  made  to  the  Essay  of  Dr.  Van 
de  Warker  already  quoted.  In  a  previous  essay,  published  in  1875,  this 
author  gives  results  of  observations  on  the  normal  movements  of  the 
uterus,  made  by  means  of  an  india-rubber  bag  distended  with  water,  and 
communicating  by  a  tube  with  a  column  of  mercury.  His  inquiries  were 
made  to  determine  the  effect  of  expulsive  efforts  made  in  various  posi- 
tions of  the  body.  It  was  found  that  descent  of  the  uterus  (indicated  by 
the  instrument),  produced  by  expulsive  effort,  was  much  greater  in  the 
standing  than  in  the  sitting  position,  the  difference  being  equal  to  j^  inch 
of  mercur}'.  It  was  also  found  that  the  difference  pioduced  by  mere  posi- 
tion, without  expulsive  action,  between  standing  and  sitting  (due  to  super- 
incumbent visceral  pressure)  was  represented  by  ^  inch  of  mercury. 
The  squatting  position,  according  to  these  experiments,  gave,  next  to  the 
actual  lying-down  position,  the  least  amount  of  pressure  on  the  uterus. 


DISPLACEMENTS,   DISTORTIONS   OF  THE    UTERUS.    169 

of  vessels  which  lie  laterally  to  the  uterus  within  the  layers 
of  the  broad  ligaments,  have  the  important  effect  of  pre- 
venting lateral  movements  of  the  uterus;  tliey  secure,  or 
help  to  secure,  the  position  of  the  uterus  in  the  middle  line 
of  the  body;  they  also  tend  very  much  to  prevent  descent 
of  the  uterus  as  a  whole,  and  they  appear  to  be  in  fact  the 
chief  means  by  which  the  uterus  is  suspended  in  the  pelvic 
cavity. 

The  round  ligaments  of  the  uterus  have  been  lately  made 
the  subject  of  inquiry  by  Martin  and  Lieberkuhn  (quoted 
by  Van  deWarker /i?^.  a'/.),  Tlae  round  ligaments  contain 
smooth  and  striped  muscular  fibres,  the  smooth  ones  at- 
tached to  the  uterus  on  its  antero-lateral  aspect  on  each 
side.  The  striped  muscular  fibres  are  inserted  by  tendin- 
ous and  fleshy  terminations  into  the  aponeurosis  of  the 
internal  oblique  muscle,  the  outer  ring  at  its  upper  and 
under  side,  while  the  smooth  fibres  pass  through  the  in- 
guinal ring  to  the  connective  tissue  on  the  mons  Veneris. 
The  round  ligaments  are  stated  by  Rainey  to  increase  in 
size  during  pregnancy.  Martin  believes  that  the  striped 
fibres  raise  the  fundus  toward  the  pubes  and  further  the 
process  of  insemination.  It  seems  probable  that  the  round 
ligaments  may  have  a  certain  effect  in  tending  to  prevent 
the  movement  of  the  fundus  uteri  backward. 

The  vagina  is  to  be  considered  as  one  means  of  support 
to  the  uterus,  and  thus  to  prevent  motion  downward.  Here 
it  is  necessary  to  point  out  that  when  we  speak  of  the 
vagina,  we  include  really  the  cellular  tissue  round  the 
vagina  and  the  processes  of  cellular  tissue  by  which  the 
vagina  itself  is  fixed.  In  a  very  interesting  paper,  Mr.  D. 
B.  Hart,  M.B.,  has  recently  discussed  the  question  of  the 
normal  support  of  the  uterus.*  He  points  out  that  the 
vagina  has  no  side  walls,  that  it  is  a  slit  parallel  to  the  pel- 
vic brim,  and  that  it  constitutes  a  pelvic  diaphragm,  the 
floor  and  roof  being  in  apposition,  and  the  uterus  being  set 
at  about  a  right  angle  to  this  diaphragm.  It  is  this  dia- 
phragm which  acts,  according  to  Mr.  Hart,  as  the  chief 
support  of  the  uterus.  He  enforces  his  argument  by  appeal 
to  the  sections  of  frozen  specimens  such  as  tliose  of  Braune. 
According  to  this  view,  the  perineum  is  a  most  important 

*  "A  Study  of  two  Mesial-vertical  Sections  of  the  Female  Pelvis  in 
Relation  to  the  Normal  Support  of  the  Uterus  and  Prolapsus  Uteri."  By 
D.  B.  Hart,  M.B.,  Obst.  Soc  of  Edin.,  Feb.,  1879. 


170  DISEASES   OF  WOMEN. 

part  of  the  support  of  the  uterus,  because,  if  it  be  partly  or 
wholly  destroyed,  the  anterior  part  of  the  vaginal  wall  slips 
over  the  posterior,  the  bladder  descends,  and  the  uterus 
follows  it.  These  arguments  are  in  substance  sound,  and 
they  appear  to  be  especially  applicable  in  regard  to  the 
etiology  of  what  may  be  termed  external  prolapsus.  The 
experiments  performed  by  Dr.  Savage  *  some  time  ago  are 
confirmatory  of  the  idea  that  the  general  cellular  tissue  of 
the  pelvis  is  exceedingly  important  as  a  means  of  holding 
the  uterus  in  position  and  preventing  descent. 

Reviewing  the  whole  subject  of  the  attachments  of  the 
uterus,  it  becomes  evident  that  the  uterus  is  held  in  its 
place  mainly  by  what  may  be  termed  the  close  packing  of 
the  pelvic  contents,  by  the  framework  of  the  vagina,  the 
framework  of  the  bladder,  and  the  broad  ligaments,  and  by 
the  vessels,  the  cellular  tissue  surrounding  the  vessels,  by 
certain  strengthening  fibres  in  various  positions,  and  in  a 
most  important  degree,  by  the  perineal  structures.  The 
attachments  are  such  that  no  considerable  motion  is  easily 
permitted  when  the  pelvic  contents  are  in  a  state  of  health. 
When  the  perineum  is  not  intact,  as  is  frequently  the  case 
in  women  who  have  borne  children,  an  important  safeguard 
is  removed.  In  the  chapter  on  Prolapsus  this  part  of  the 
subject  will  be  again  considered. 

The  motions  of  the  uterus  may  be  described  as  follows: 
It  has  an  upward  motion  and  a  downward  motion,  very 
little  lateral  motion,  but  more  anterior  or  posterior  motion. 
It  would  be  probably  correct  to  say  that,  in  a  state  of  health, 
the  range  of  upward  and  downward  motion  does  not  exceed 
two  inches,  while  the  range  of  anterior  and  posterior  motion 
is  generally  not  more  than  one  inch  and  a  half.  The  extent 
of  lateral  motion  is  probably  one  inch. 

But  the  motion  of  the  uterus  is  not  a  simple  motion. 
The  uterus  being  fixed  chiefly  at  its  middle  part,  when  any 
force  begins  to  act  upon  it  a  compound  motion  results. 
Thus  tlie  uterus,  when  pushed  downward,  as  in  the  act  of 
straining,  does  not  retain  its  longitudinal  axis  in  the  same 
position,  but  it  may  be  tilted  to  a  certain  degree  at  the 
same  time.  Thus  the  uterus  may  descend  as  a  whole,  but 
the  upper  part  of  it  may  descend  more  than  the  middle 
part.  In  such  a  case  we  have  descent,  together  with  what 
has  been   termed  "version,"  but  which  would  be  more  cor- 

*  "  Illustrations  of  the  Surgery  of  the  Fepiale  Sexual  Organs," 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    17I 

rectly  designated  "rotation"  (on  its  transverse  axis  of  sus- 
pension). But  there  arises  a  further  complication.  If  the 
uterus  were  a  solid  rod,  the  axis  of  the  organ  would  be 
always  the  same,  thougl;  it  would  not  be  always  in  the 
same  place.  But  inasmuch  as  the  uterus  is  in  a  certain  de- 
gree a  pliable  body,  it  is  liable  to  be  bent  and  the  shape  of 
its  axis  changed.     We   thus   have   three  kinds  of  motion 

Fio.  32.* 


possible.  For  instance,  there  may  be — i.  Movement  down- 
ward. 2.  Tilting  of  the  uterus  (version,  or,  as  above  sug- 
gested, more  properly  "  rotation")  on  the  transverse  axis. 
3.   Bending  or  flexion  of  the  uterus. 

In  the  accurate  estimate  of  this  conjunction  of  motions 
we  have  the  basis  for  the  true  pathology  of  uterine  flexions 
and  displacements.     The  natural  movements  of  the  uterus 

*  Fig.  32,  copied  from  Schultze,  represents  his  notion  as  to  the  condi- 
ijon  of  the  pierus  when  the  bladder  is  empty. 


172 


DISEASES   OF    WOMEN. 


are  usually  complicated,  as  above  described,  descent  di- 
rectly downward,  for  instance,  being  less  common  than 
downward  descent  together  with  a  little  rotation  (version) 

Fig.  33.* 


and  a  little  flexion.  When  the  uterus  is  in  a  state  of  health 
it  quickly  returns  to  its  normal  position  as  soon  as  the  ap- 
plication of  the  moving  force  ceases,  and  there  is  little 
doubt  that  these  slight  oscillations  habitually  occur  during 

*  F'<^-  33  representp  the  normal  range  of  motion  of  the  uterus. 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    1 73 

changes   of  position  of  the  body,  during  exercise,  during 
the  natural  expulsive  efforts,  etc. 

The  particular  motion  of  the  uterus  about  which  there 
does  not  appear  to  be  uniformity  of  opinion  is  that  con- 
nected with  evacuation  of  tlie  contents  of  the  bladder.  It 
is  the  opinion  of  some,  as  already  stated  at  p.  166,  that  the 
body  of  the  uterus  habitually  falls  or  moves  forward  as  the 
urine  escapes  from  the  bladder,  and  that  this  anteversion 
and  flexion  of  the  uterus  is  a  perpetually  recurring  event. 
I  believe  this  opinion  to  be  incorrect.  It  is  possible  there 
may  be  a  slight  tilling  or  rotatory  movement  forward  when 
the  bladder  becomes  emptied,  but  the  descent  of  the  top  of 
tlie  fundus  uteri,  under  such  circumstances,  does  not  in  a 
state  of  health,  according  to  my  observation,  exceed  half  an 
inch  in  amount,  whereas,  according  to  Schultze's  (see  Fig. 
32),  the  top  of  the  fundus  descends  as  much  as  two  inches, 
or  even  more,  on  complete  evacuation  of  the  vesical  con- 
tents. 

When  the  bladder  is  rather  fuller  the  uterus  as  a  whole 
may  be  pushed  backward  a  little  without  being  bent,  and 
when  the  rectum  is  very  much  distended,  the  uterus  may  as 
a  whole  be  pushed  forward.  When  expulsive  efforts  are 
made,  it  is  obvious  that  the  result  will  be  different  accord- 
ing to  the  condition  of  tlie  rectum  and  bladder.  If  both 
are  in  a  medium  state  of  fulness  the  uterus  will  be  made  to 
descend  toward  the  floor  of  the  pelvis,  and  the  posterior 
part  of  the  vagina  will  descend  with  it.  There  may  be 
little  rotation  (version)  or  flexion  under  such  circumstances. 
When  the  bladder  is  very  full  the  expulsive  effort  may,  as 
has  been  shown  by  experiments  performed  by  Dr.  Braxton 
Hicks,  result  in  a  retroversion  of  the  uterus.  Not  long 
since  I  had  under  my  care  a  young  lady  suffering  from  ret- 
roversion and  flexion,  which  was  certainly  due  to  long- 
continued  retention  of  urine  during  a  long  railway  journey. 
When  the  bladder  is  not  distended  the  expulsive  effort  pro- 
jects the  uterus  downward  and  at  the  same  time  may  pro- 
duce extreme  anteversion.  These  are  of  course  extreme 
events,  and  they  are  here  mentioned  because  there  can  be 
little  doubt  that  they  are  only  exaggerations  of  what  proba- 
bly happens  every  day,  but  to  a  much  less  degree,  and 
when  also  the  uterus  and  its  surroundings  are  in  a  state  of 
health.  The  accompanying  drawing  (Fig.  ^^)  exhibits 
what  may  be  described  as  the  normal  extent  of  the  mo- 
tions of  the  healthy  uterus,     a  a'  shows  the  position  of  the 


1/4  DISEASES   OF  WOMEN. 

uterus  in  a  state  of  rest;  b  b'  shows  the  degree  of  anterior 
tilting  (or  rotation)  which  occurs  under  various  circum- 
stances— emptying  of  the  bladder,  etc.;  and  c  c'  shows  the 
degree  of  posterior  rotation  which  may  occur.  It  will  beob- 
served  that  in  anterior  rotation  the  os  is  carried  backward, 
whereas  in  posterior  rotation  the  os  is  carried  forward. 
Moreover,  in  both  the  latter  cases  theos  is  seen  to  be  rather 
lower  than  usual  in  the  pelvis. 


CHAPTER  XIV. 


Displacements,  Distortions  (Flexions),  of  the  Uterus. 
— 2.  Pathology  and  General  History. 

Nomenclature — Flexion,  Distortion,  Version.  Prolapsus — Complex  na- 
ture of  Cases — Frequency  of  Distortions  and  Displacements — Statistics 
from  Author's  Hospital  Practice — Statistics  from  Private  Practice. 

Nomenclature. — When  the  uterus  is  bent  upon  itself  it 
is  said  to  be  flexed,  and  when  the  fiexion,  passing  beyond 
the  normal  limit,  has  become  chronic  the  malady  is  a  dis- 
tortion of  the  uterus.  When  the  alteration  of  shape  is 
known  to  have  occurred  after  puberty,  or  thereabouts,  the 
affection  is  properly  spoken  of  as  a  distortion.  Malfor- 
mations of  the  uterus  are  congenital.  Occasionally  it  is 
rather  difficult  to  distinguish  a  malformation  from  a  distor- 
tion of  the  uterus. 

By  version  of  the  uterus  {rotation  backward  or  forward  on 
the  transverse  axis)  is  meant  an  inclination  of  the  organ  for- 
ward, backward,  or  to  the  side,  as  the  case  may  be,  consti- 
tuting anteversion,  retroversion,  lateriversion  {right  or  left). 

It  is  very  generall)'  the  case  that  version  of  the  uterus  is 
conjoined  7vith  flexion  of  the  organ,  though  in  some  cases  the 
axis  of  the  uterus  is  actually  undisturbed,  and  there  is  ver- 
sion pure  and  simple. 

Another  result  generally  occurs,  viz.,  that  there  is  a  cer- 
tain degree,  often  a  very  great  degree,  of  displacement  of  the 
?//^;7/j-,  conjoined  with  the  distortion.  Flexion  of  the  uterus 
necessarily  implies  a  degree  of  displacement  of  the  bod}'  of 
the  uterus,  or  of  the  cervix.  Thus,  in  a  case  of*  retroflex- 
ion the  fundus  uteri  is  relativ'ely  much  lower  in  the  pel- 
vis than  in  the  healthy  uterus,  and  it  is  thus  "d  splaced." 
But  there  are  two  distinct  kinds  of  displacement.  Thus, 
sometimes  we  find  the  uterus  as  a  whole  not  materially  dis- 


DISPLACEMExMTS,   DISTORTIONS   OF   THE    UTERUS.    1/5 

placed  from  its  proper  position  in  the  pelvis,  but  certain 
parts  of  it  are  removed  from  their  proper  place.  More 
often,  however,  it  is  the  fact  that  there  is  both  a  relative  and 
a  general  displacement  of  the  uterus.  Nothing  is  more 
common,  indeed  it  is  the  rule,  to  which  there  are  excep- 
tions, to  find  considerable  descent  of  the  uterus  in  the  pel- 
vis, conjoined  with  marked  distortion. 

The  word  prolapsus  is  used  rather  widely.  By  some  it  is 
restricted  to  cases  where  the  uterus  is  only  partially  pro- 
truded, the  term  procidentia  being  employed  to  designate 
complete  extrusion  of  the  uterus.  Using  the  term  prolap- 
sus in  its  widest  sense,  we  find  prolapsus  associated  very 
frequently  indeed  with  distortion  of  the  uterus,  and  this  ap- 
plies both  to  cases  where  the  prolapsus  is  slight  in  degree, 
or  so  severe  as  to  amount  to  procidentia. 

Numerous  figures,  illustrative  of  the  above  remarks,  will 
be  found  in  the  succeeding  chapters. 

Co.MPLEX  Nature  of  Cases. — From  the  foregoing  re- 
marks it  will  be  evident  that  there  are  a  multitude  of  compli- 
cations possible,  and  as  a  fact  it  is  very  rare  to  meet  with 
any  one  of  the  conditions,  version,  flexion,  or  prolapsus  of 
the  uterus  in  a  simple  and  unmixed  form. 

This  is  a  point  of  considerable  importance,  for  it  is  im- 
]->ossible,  unless  it  is  duly  regarded^,  to  make  any  advance  in 
knowledge  of  the  subject.  Cases  as  they  are  met  with  in 
practice  are  generally  complex:  they  are  as  a  rule  complex 
in  more  than  one  sense  of  the  word.  The  complexity  is  not 
merely  a  mechanical  one — there  are  also  various  vital  or 
functional  disturbances  entering  into  and  complicating  al- 
most every  case.  Thus,  flexions  and  displacements  of  the 
uterus  are  almost  invariably  only  a  part,  though  a  very  im- 
])ortant  part,  of  the  affection.  The  condition  of  the  general 
liealth,  the  condition  of  the  uterine  tissues,  are  qualities 
liable  to  vary  exceedingly  in  different  cases,  and  when  we 
consider  the  number  of  possible  varieties  in  the  shape  and 
position  of  the  uterus,  it  is  evident  that  the  number  of  pos- 
sible complications  is  almost  endless.  Thus,  to  say  that  a 
particular  patient  is  affected  with  an  anteflexion  of  the 
uterus  is  to  convey  very  little  actual  information;  the  case 
may  be  trifling  in  importance,  or  it  may  be  serious;  it  may 
be  safely  left  to  itself,  or  it  may  require  much  and  skilful 
attention  to  be  remedied.  We  should  require  to  know  the 
history  of  the  case,  the  precise  degree  of  the  anteflexion, 
the  precise  position  of  the  uterus  as  a  whole  in  the  pelvis, 


1/6  DISEASES   OF  WOMEN. 

the  physical  condition  of  the  tissues  of  the  uterus,  the  size 
and  thickness  of  its  walls;  and,  in  forming  a  due  estimate  of 
the  case,  the  general  condition  and  activity  of  the  nutritive 
process  would  form  a  ver}'  essential  element. 

Frequency  of  Distortions  and  Displacements  of  the 
Uterus. — It  is  a  matter  of  considerable  interest  to  de- 
termine the  actual  frequency  with  which  these  disorders  of 
the  uterus  are  met  with  in  practice.  The  following  is  a 
contribution  on  this  subject  from  my  own  experience: 

During  a  period  of  a  little  over  four  years,  from  August, 
1865,  to  December,  1869,  I  kept  notes  of  all  cases  treated  in 
my  out-patients'  room  at  University  College  Hospital.  The 
number  of  recorded  cases  of  all  kinds  is  1,205.*  Of  these, 
714  presented  uterine  symptoms.  Of  these  714,  620  were 
subjected  to  an  internal  examination,  and  the  diagnosis 
thus  arrived  at.      In  94  no  such  examination  was  made. 

Of  the  620  examined  cases,  61,  or  9.8  per  cent,  were  set 
down  as  suffering  from  absence  or  malformation  of  uterus, 
or  various  symptomatic  affections  only. 

In  182,  or  29.3  per  cent,  the  patients  were  found  to  be 
suffering  from  fibroid  tumor,  cancer,  or  pelvic  cellulitis. 

In  377,  or  60.8  per  cent,  the  shape  of  the  uterus  was  ma- 
terially changed  or  its  position  markedly  changed. 

These  377  cases  are  further  resolved  into 


Flexions 


j  Retroflexions,  112  >      ^  . 
I  Anteflexions,    1S4  f      '^o 


Prolapsus 81 


377 


Further,  "  the  flexion  cases  were  very  generally  attended 
with  textural  alterations  of  the  uterus,  congestive  hypertro- 
phy, etc.,  which,  in  accordance  with  present  views  would 
be  termed  congestion;  but  it  is  precisely  in  those  cases 
where  the  symptoms  of  irritation  were  most  marked  that 
severe  and  well-established  flexions  w'ere  found  to  exist." 

It  thus  appears  that  in  60.8  per  cent  of  these  hospital  out- 
patient cases  which  presented  uterine  symptoms  of  suffi- 
cient importance  to  suggest  the  necessity  for  making  an 
examination,  marked  physical  changes  in  the  form,  shape, 
or  position  of  the  uterus  were  detected. 

The  total  number  of  cases  recorded  was,  as  I  have  before 
stated,  1,205,  '^^  which  714  are  accounted  for  in   the  above 

*  These  data,  the  results  of  hospital  experience,  were  first  published  in 
the  last  edition  of  this  work,  1S72. 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    1 77 

analysis.  There  remain  491  cases,  which  include  many  of 
syphilis  or  gonorrhoea,  pregnane}',  general  debility,  over- 
lactation,  diseases  of  the  bladder  or  external  generative  or- 
gans, phlegmasia  dolens,  tumors  or  inflammations  of  the 
ovaries,  cases  of  doubtful  diagnosis,  cases  of  disease  of 
other  than  the  generative  organs,  etc. 

The  foregoing  statistics  give  the  proportion  in  which  dis- 
tortions and  displacements  are  liable  to  be  observed  in  the 
case  of  hospital  patients,  in  London  at  least.  Turning  from 
these  results  of  public  hospital  practice  it  is  more  difficult 
to  arrive  at  results  which  will  command  attention  as  to  the 
frequency  of  uterine  distortions  and  displacements  in  the 
class  of  patients  ordinarily  denominated  "private"  patients 
and  the  majority  of  which  belong  to  the  better  classes  of 
society.  I  have,  however,  extracted  the  following  particu- 
lars relating  to  six  years  of  recent  private  practice  with  the 
view  of  arriving  at  some  conclusion  on  the  question  as  to 
tlie  relative  frequency  of  various  forms  of  uterine  disease. 

It  must  be  premised  that  the  six  years'  statistics  given 
below  are  imperfect  in  one  way,  for  they  do  not  include  a 
number  of  cases,  particularly  those  seen  in  consultation 
practice  away  from  my  own  residence,  which  have  unavoid- 
ably escaped  being  recorded. 

The  total  recorded  cases  in  six  years  (r,i4o)  include — 

Cancer,  uterine  or  vaginal 27 

Fibroid  tumor  and  polypus 60 

Diagnosis  of  pregnancy 33 

Flexions,  and  displacements  of  the  uterus  (see  explana- 
tory statement  below) 709 

Miscellaneous,  including 

a.  Diseases  of  other  than  sexual  organs 

b.  Cases  of  disease  of  sexual  organs,  no  physical     311 

examination 

c.  Various  diseases  of  sexual  organs  not  included 

in  foregoing  list 

1 140 

It  is  Stated  in  the  foregoing  list  that  709  patients  were 
affected  with  flexions  or  displacements  of  the  uterus.  This 
statement  requires  a  more  complete  explanation.  There 
were  probably  several  other  patients  who  would  have  been 
found  to  be  suffering  from  these  affections  had  an  examina- 
tion been  made.  The  709  cases  are  put  together  because 
they  evidently  belonged  to  one  class.  The  symptoms  were 
so  severe  or  troublesome  that  an   examination  was  impera- 


178  DISEASES   OF  WOMEN. 

tive,  and  the  result  of  the  investigation  was  to  show  that 
the  symptoms  were  dependent  on  the  uterus.  In  a  few  of 
the  cases  where  it  is  expressly  stated  the  uterus  was  found 
normal,  the  cases  are  still  left  in  this  categon.-,  because  the 
symptoms  observed  were  such  as  are  ordinarily  present  in 
cases  of  flexion  or  displacement,  and  no  disease  of  any  other 
organ  was  found  to  account  for  them. 

Flexions  (ante-  4S8,  retro-  180) 663 

Uterus  prolapsed  without  flexion 6 

Uterus  simply  too  large  or  too  long 11 

Hypertrophic  cenrical  elongation 3 

Uterus  normal 4 

Cases  of  alternate  ante-  and  retroflexion 2 

Lateriflexion 3 

Flexions  combined  with  pregnancy 12 

Total  709 

Under  the  head  "  Miscellaneous"  are  included  various 
slight  cases  of  disorder  of  the  sexual  organs,  in  some  of 
which  examination  was  made,  and  in  many  not;  it  includes 
also  cases  diagnosticated  to  be  disease  of  the  ovaries  by 
physical  examination  or  otherwise.  It  also  includes  some 
few  cases  of  patients  who  were  not  found  to  be  affected  with 
diseases  of  the  sexual  organs  at  all.  The  number  of  cases 
of  the  latter  class  is  not,  however,  enough  to  vitiate  any 
numerical  conclusion  to  which  the  figures  would  appear  to 
lead- 
Speaking  generally  of  the  foregoing  statistics,  they  may 
be  summed  up  as  follows: 

Of  1 100  patients  believing  themselves  to  be  affected  with 
some  disorder  r'^erable  to  the  sexual  organs,  or  believed  to 
be  so  affected  by  the  practitioner  under  whose  care  they 
had  been,  after  a  careful  investigation  of  the  case  and  from 
the  results  of  physical  examination,  about  700  were  found 
to  be  suffering  from  well-marked  flexion  or  displacement  of 
the  uterus;  87  were  affected  with  cancer  or  fibroid  tumor; 
there  remain  rather  over  300  cases  accounted  for  under  va- 
rious heads  in  the  foregoing  list. 

The  statistics  of  my  own  private  practice  thus  show  that 
in  about  70  per  cent  of  patients  applying  for  advice,  flexions 
and  displacements  existed,  and,  in  my  judgment,  proved  to 
be  the  essential  cause  of  the  sufferings  of  which  the  patients 
complained.  When  it  is  stated  that  flexions  and  displace- 
ments existed  in  this  large  percentage  of  cases,  it  is  not  to 


DISPLACEMENTS.   DISTORTIONS  OF  THE   UTERUS.   I79 

be  inferred  that  these  constituted  the  sole  Tnalndies  f-esent. 

Few  of  these  cares  were  without  . 

kinds.     But  almost  the  wh-^^e  cf 

severe  ones,  none  being   :•  ;ne 

patient  was   sunering  or   ;         -  .  e  in 

which  the  diagnosis  was  at  ail  doubtiiii. 


CHAPTER    XV. 

Displacements  axd  Distortioxs  or  the  Uterus  (Flex- 
ions)—3.  Etiology. 

Etioi.^.-v — >-A:"i:'^  .-'^   rAi?<  ■-  ?'%  A!r-    P-Artice.i_- - --- 

o:  >: 

Uterus  ::..n:  v 

—Physical    P: 

a.     Elxcilinj::     Ac  .r    .5 — (.">  r:-r,\c-:  s? — >y<:^.      :_\;r;  <r<  —  ^.>^::i. 

Oxufviiions — Miiriogie.     V   General  Causes. 

For  some  few  years  past  II  ^  to 

ascertain  the  cause  of  the  ci-.  .  .    in 

cases  of  this  kind  coming  under  rr  In  a  consider- 

able number  of  the  cases  I  found  :  .  .  -,  .^,  -^  ;.,  the 

previous  history*  particular  causes  t  ; ur- 

rence.     Due  care  has  been  taken   iv.    j^...    ..   ..>  v,-.  c.-..\  as 

possible  against  sources  of  fallacy  in  tracing  the  relation  of 
he  cause  and  effect. 
It  is  remark.ible  how  frequentir  the  narticutar  cause  of 
•    "'.    "  "\  "     ,  ,     -      ^j. 

^     — ta 


1  >  t  i  .1  i.  \. 


I  have  selev :  -    f  cr.sr?  rrVrrtrd  ;!::-:-::  six 

years  540  cases  in  wir.ch   .  ar- 

ried,  was  sterile,  and  in  w  th 

ante-  or  reirv>-rtexion.     I  have  ed  lor  the 

moment  cases  of  patients  who .  . .:.  as  in  such 

cases  child^i-th.  or  the  sequelae  of  child-bed,  introduce  dis- 
turbing considerations. 

It  thus  appears  that  in  ^*^.  or  43  per  cent,  of  cases  of 
riexion  in  single  women,  or.  if  marrievi,  sterile,  the  cause 
was  distinctly  traced  to  some  one  of  the  above-mentioned 
agencies. 

It  is  right  to  state  that  in  three  of  the  above  cases  the  pa- 


l8o 


DISEASES   OF  WOMEN. 


tient  had  had  a  miscarriage,  accident  or  strain  having  pro- 
duced apparently  the  miscarriage  as  well  as  the  displace- 
ment, or,  to  speak  more  correctly,  the  accident  or  strain  was 
responsible  both  for  the  displacement  and  the  miscarriage. 

340  Cases  of  Single  or  Sterile  Patients  Affected  with  Uterine  Flexions. 


The  flexion  distinctly  traced  to 


Retro- 

Ante- 

flexions  flexions 

Total. 

13 

49 

62 

II 

18 

29 

6 

9 

15 

8 

7 

15 

I 

3 

4 

I 

I 

2 

I 

I 

2 

0 

I 

I 

0 

I 

I 

I 

0 

I 

2 

II 

13 

0 

3 

3 

0 

I 

I 

44* 

lost 

149 

Strains,  lifting,  carrying,  nursing,  standing,  danc- 
ing, gymnastics,  croquet,  swimming,  etc.... 

Falls,  or  other  accidents 

Horse  exercise 

Over-walking 

Organ  or  harmonium-playing 

Long  railway  journey 

Retention  of  urine  in  railway  journey 

Fright 

Sea-sickness  (three  months'  voyage) 

Measles 

Scarlet  fever  or  typhoid  fever 

Menstruation  checked  by  cold 

Menstruation  checked  by  sea-bathing 


Strains  resulting  from  efforts  in  lifting,  nursing,  etc..  con- 
stituted a  very  common  cause — 62  out  of  149  ca?es.  They 
most  commonly  produce  the  effect  in  patients  who  under- 
take such  exertions  without  proper  training  or  strength. 
Nursing  and  lifting  sick  relatives  appear  to  be  very  danger- 
ous. Lifting,  or  occupations  involving  much  standing, 
were  responsible  in  many  cases.  "  Stretching  up  to  a  cord," 
"drawing  the  cork  of  a  bottle,"  "carrying  a  child,"  "strain 
at  archery,"  "moving  furniture,"  "  rowing,"  "use  of  sew- 
ing machine,"  "lifting  a  patient  from  the  ground,"  "lifting 
w^ashstand,"  were  the  causes  traced  in  other  instances. 
Unnecessary  gymnastic  feats,  excessive  standing  at  croquet, 
one  or  two  cases  traceable  to  excessive  swimming,  may  also 
be  mentioned. 

"  Falls,"  or  other  accidents,  include  many  cases  in  the 
tabular  list  above  given.  "  A  complete  somersault  down  a 
flight  of  steps,"  "thrown   from  a  carriage,"   "fall   from   a 


*  Selected  from    83  cases  ]  _ 
t  Selected  from  257  cases  [  ~  34 


DISPLACEMENTS,    DISTORTIONS   OF  THE   UTERUS.    l8l 

carriage,"  "  thrown  from  a  horse,"  "fall  from  a  horse,"  falls 
on  the  back,  on  the  ground,  down-stairs,  etc. — under  the 
foregoing  heads  I  find  cases  of  retroflexion  recorded. 
"Jump  from  a  carriage,''  "slipped  down  flight  of  stairs," 
"fall  from  back  of  dog-cart,"  "fall  from  horse,"  "slipped 
down-stairs,"  "fall  down  steps,"  "jump  from  a  horse," 
"fall  from  a  horse  and  horse  rolled  over  her" — under  these 
heads  cases  of  anteflexion  could  be  quoted. 

Horse  exercise  was  clearly  traced  as  a  cause  in  several 
cases.  In  one  case  it  indirectly  led  to  displacement, owing 
to  prolonged  retention  of  urine.  In  weakly  young  women, 
imperfectly  trained  to  it,  horse  exercise  appears  decidedly 
injurious. 

"Over-walking"  includes  several  cases.  "Long  moun- 
tain walks,"  "daily  long  walks,"  and  "long  walks  to  catch 
a  train,"  are  causes  traced  in  some  retroflexion  cases. 
"  Long  walks  up-hill,"  "very  fatiguing  walk,"  "  walk  during 
menstrual  period,"  etc.,  in  certain  cases  of  anteflexion. 
Organ  or  harmonium  playing  was  found  injurious  in 
a  few  cases.  Retention  of  urine  during  long  railway 
journey,  fright,  etc. — these  cases  require  no  particular 
mention. 

There  were  fourteen  cases  in  which  the  cause  assigned 
above  is  measles,  scarlet  fever,  or  typhoid  fever.  The  rea- 
son for  introducing  these  cases  is,  that  the  details  on  inves- 
tigation proved  that  the  uterine  affection  had  occurred 
from  ordinary  walking  during  convalescence  from  the 
fever.  The  conclusion  formed  was  that  the  uterus,  enfee- 
bled in  common  with  the  other  organs  of  the  body,  gave 
way  under  ordinary  exertion,  and  the  preceding  fever 
was  thus  really  responsible  for  the  resulting  uterine  affec- 
tion. 

The  causes  of  uterine  distortions  and  displacements  may 
be  divided  into  three  classes — predisposing,  exciting,  and 
general. 

PredispL  "ising : — 

Undue  softness  of  the  uterus — 

From  malnutrition  (chronic  starvation). 
From  sub-involution  following  pregnancy. 
Physical   general   prostration   and   weakness,   as   from 

fever,  etc. 
Rupture  of  perineum. 
Previous  pregnancy. 


l82  DISEASES   OF   WOMEN. 

Exciting: — 

Accidents — ■ 

Strains. 

Falls. 

Railway  and  carriage  accidents. 
Over-exercise — 

Long  walks  or  drives. 

Excessive  exercise  during  menstruation. 
"  "  "        pregnancy. 

Exercise  too  soon  after  confinement. 
Special  exercises — • 

Horse  exercise. 

Gymnastics    (inappropriate    or    injudiciously   se- 
lected). 

Croquet,  lawn-tennis,  etc.  (in  excess). 
Special  occupations — 

Requiring  much  standing,  as  counter  work. 

Requiring  carrying  and  lifting,  as  nursing. 

Washing. 

Use  of  sewing  machine. 
Straining  in  defaecation,  etc. 
Marriage. 

General. Se.&  remarks  later  on. 

Of  the  predisposing  causes,  undue  softness  of  the  uterus  is 
perhaps  the  most  important.  It  may  be  due  to  malnutri- 
tion either  in  a  single  woman,  or  in  one  who  has  borne 
children.  This  condition  of  the  uterus  has  been  already 
described  (p.  98).  General  prostration  and  weakness,  as  from 
the  effects  of  fever,  appear  to  be  powerful  predisposing 
causes  (see  list  cf  cases  enumerated  at  p.  180).  Clinical 
facts  show  that  uterine  flexions  are  liable  to  be  initiated  by 
exercise  or  movement  taken  shortly  after  prostration  from 
fevers.  Rupture  cf  the  perineum  is  a  special  predisposing 
cause:  the  support  of  the  lower  part  of  the  vaginal  canal  is 
taken  away,  and  this  is  a  powerful  predisposition  to  dis- 
placement of  the  uterus  and  to  flexion  of  the  organ. 

Previous  pregnancy  predisposes  to  flexion  in  several  ways. 
The  influence  of  rupture  of  the  perineum  (if  it  exist)  has 
already  been  alluded  to.  But  in  other  ways  a  predisposi- 
tion may  exist.  Thus,  if  the  uterus  is  left  in  a  state  of  sub- 
involution, the  mere  weight  of  the  organ  tends  to  produce 
flexion.  If  the  organ  remains  softer  than  usual,  as  well  as 
in   a   state    of    sub-involution,   the    predisposition    will    be 


DISPLACEMENTS,   DISTORTIONS   OF   THE   UTERUS.    I  S3 

greater.  Again,  the  loosening  of  the  attachments  of  the 
uterus  is  frequently  great  during  pregnancy  and  labor,  and 
even  if  no  lesion  is  discoverable,  the  normal  fixation  of  the 
uterus  may  have  been  lost  and  a  predisposition  to  flexion 
created. 

Repeated  pregnancies  in  women  badly  nourished  has  a 
tendency  to  weaken  the  uterus  very  much.  The  uterus  has 
little  rest — it  has  scarcely  time  to  recover  from  the  effect 
of  one  pregnancy  before  another  occurs.  In  the  end  the 
uterus  becomes  flexed,  the  flexion  is  confirmed,  and  either 
abortions  or  sterility  (secondary)  result. 

Excidne;  Causes  of  Flexions. — Accidents,  including  strains, 
fails,  and  rail  way  or  carriage  accidents,  are  very  important. 
It  has  hardly  as  yet  come  to  be  recognized  as  a  fact  that 
the  uterus  may  be  very  seriously  displaced  and  injured  by 
severe  accidents.  The  number  of  cases  of  severe  injury  to 
the  uterus  from  these  causes  recorded  in  my  case-books  is 
considerable.  The  nature  of  the  injury  is  generally,  as 
experience  has  informed  me,  not  understood  at  the  time  of 
the  accident:  the  patient  feels  ill,  generally  no  bones  are 
broken,  there  is  a  severe  shock,  the  effects  of  which  last  a 
few  hours  or  a  few  days  or  longer,  and  gradually  the  patient 
loses  the  pain  and  no  further  notice  is  taken  of  it.  But 
later  on  it  is  discovered  tliat  the  patient  is  more  or  less 
completely  incapacitated,  and  careful  examination  reveals 
the  fact  that  the  uterus  is  displaced  and  distorted,  investi- 
gation of  the  facts  conclusively  showing  that  the  discom- 
fort or  incapacity  dates  from  a  certain  accident.  One  of 
the  first  cases  of  the  kind  which  came  under  my  notice  was 
that  of  a  young  lady  who,  travelling  by  train,  had  been 
rolled  down  a  railway  embankment,  and  had  become  af- 
fected with  acute  retroflexion  of  the  uterus  as  the  result. 
The  record  of  many  cases  of  an  analogous  kind  which  is  in 
my  possession,  gives  unmistakable  proof  of  the  effect  of 
accidents  in  producing  such  displacements  and  distortions. 

The  effect  of  a  severe  concussion  on  the  uterus  varies  in 
different  cases,  and  it  varies  according  as  it  is  accompanied 
or  not  by  a  severe  strain.  It  is  not  uncommon  for  the  con- 
cussion and  the  strain  to  come  together.  There  is  the  fall, 
and  the  muscular  effort  to  avoid  the  fall  or  accident.  In 
the  latter  case  the  displacement  of  the  uterus  is  likely  to  be 
greater.  The  facts  in  my  possession  show  that  the  uterus 
may  be  forcibly  driven  downward  to  the  floor  of  the  pelvis, 
or  to  the  back  part  of  the  pelvis — into  one  corner  of  it  as  it 


l84  DISEASES  OF  WOMEN. 

were — or  that  it  maybe  actually  driven  out  of  the  vagina— 
[at  least  I  have  known  of  one  case  of  the  latter  kind  in  a 
patient  who  had  had  a  child,  and  \vho,  while  in  the  standing 
position,  slipped  from  the  table  on  which  she  was  standing 
to  the  floor].  More  generally  the  uterus  is  not  only  driven 
downward  to  the  floor  of  the  pelvis,  but  it  is  bent  backward 
or  forward,  very  acutely,  at  the  same  time.  It  was  believed 
by  Dr.  Squarey  that  rupture  of  the  uterine  fibres  sometimes 
occurs  in  the  suddenly  occurring  acute  flexion  cases,  and  I 
consider  it  quite  possible  that  it  is  so.  At  all  events,  it  is 
not  uncommon  for  some  blood  to  escape  from  the  vagina 
after  such  accidents.  The  effect  of  the  blow  or  concussion 
will  vary  probably  according  to  the  position  of  the  patient 
at  the  time,  and  the  condition  of  the  uterus,  but  when  the 
case  is  investigated  it  is  found  that  the  uterus  remains  on 
the  floor  of  the  pelvis,  or  in  one  corner  of  it,  or  that  it  is 
anteflexed  or  retroflexed.  It  is  important  to  note  that  when 
bones  are  broken  or  other  notable  injuries  received,  tlie 
internal  injury  to  the  uterus  may  escape  notice.  Two  cases 
of  this  kind  occur  to  me  to  mention.  One  was  that  of  a 
lady  who  fell  and  injured  the  sacrum,  was  laid  up  b}'  that 
injury  for  some  time,  then  went  about  and  rode  on  horse- 
back much,  subsequently  becoming  paraplegic.  The  para- 
plegia was  naturally  set  down  to  the  spinal  injury,  but  it 
proved  to  be  due  to  a  retroflexion  of  the  uterus,  and  the 
patient  was  completely  cured  by  restoration  of  the  uterus. 
Another  was  that  of  a  young  lady  who  fell  and  broke  her 
arm:  some  months  after  that  obstinate  nausea  attracted 
attention,  and  it  was  found  that  the  uterus  had  been  vio- 
lently displaced  and  pushed  into  one  of  the  posterior  cor- 
ners of  the  pelvis. 

Violent  straining  may  produce  severe  flexion.  Of  this 
class  of  cases  may  be  mentioned  one  in  whicli  the  patient, 
quite  unaccustomed  to  such  an  exertion,  lifted  a  helpless 
invalid  from  the  floor,  who  had  suddenly  rolled  out  of  his 
chair,  the  result  being  severe  flexion.  Another,  that  of  a 
young  lady,  who  in  a  spirit  of  bravado  carried  a  very  heavy 
cheese  across  the  room,  and  became  forthwith  an  invalid 
from  severe  flexion  of  the  uterus. 

Long  walks  may  produce  at  once  acute  flexion,  or,  con- 
tinued from  day  to  daj^  may  slowly  give  rise  to  flexion. 
Very  long  walks  are  certainly  dangerous  to  those  unaccus- 
tomed to  them.  Young  recently  married  women,  untrained 
and  unfit  for  such  continuous  exertion,  often  inflict  very 


DISPLACEMENTS,   DISTORTIONS   OF   THE    UTERUS.    1 85 

serious  injury  upon  themselves  by  walking  about  all  day 
during  the  honeymoon.  Long  mountain  walks  should  not 
be  undertaken  by  young  women  unless  trained  for  the  pur- 
pose and  in  robust  health;  and  if  a  predisposition  to  flexion 
exists,  much  harm  may  be  done  by  them.  "A  long  walk 
of  ten  miles  to  catch  a  train"  produced  severe  retroflexion. 
Long  walks  often  inflict  serious  injury  on  young  women  at 
school  who  do  not  happen  to  be  "strong,"  and  who  are 
tlierefore  predisposed  to  suffer  from  flexion. 

It  appears  that  long  walks  are  more  dangerous  if  under- 
taken during  the  menstrual  period,  no  doubt  because  the 
uterus  is  at  that  time  heavier,  larger,  and  more  vascular, 
and  therefore  more  liable  to  become  displaced.  Long 
walks  are  not  uncomm(jnly  the  cause  of  abortion  during 
the  second  or  third  month;  the  uterus  becoming  displaced 
or  flexed,  the  abortion  is  thus  produced.  Another  impor- 
tant class  of  cases  is  that  in  which  walking  in  excess  is 
undertaken  too  soon  after  labor,  while  the  uterus  is  still 
heavy,  and  in  a  state  of  sub-involution. 

Horse  exercise  may  cause  flexion  of  the  uterus.  It  may 
be  produced  suddenly  and  at  once,  or  more  gradually.  It 
is  not  so  liable  to  happen  if  the  individual  be  strong  and 
properly  trained  to  it;  but  evidence  that  could  be  adduced 
seems  to  show  that  it  is  a  kind  of  exercise  not  free  from 
liability  to  produce  serious  uterine  mischief,  even  when 
judiciously  managed.  The  evidence  shows  that  the  uterus 
is  liable  to  be  pushed  downward  on  the  floor  of  the  pelvis, 
and  generally  very  decidedly  flexed  backward  or  forward. 
If  there  be  no  particular  predisposition  to  flexion  horse 
exercise  may  do  no  harm,  but  it  is  never  certain  that  it 
will  not. 

Some  few  cases  of  severe  flexion  were  undoubtedly  traced 
to  too  severe  gymnastic  exercises.  In  two  cases  severe 
flexions  were  produced  by  jumping  down  from  a  consider- 
able height;  in  one  severe  and  most  troublesome  retro- 
flexion was  produced  by  the  feat  of  raising  tlie  body  from 
tlie  horizontal  position  without  the  use  of  the  arms.  In 
two  cases  rowing  was  distinctly  traced  as  the  cause. 

Dr.  Aveling.  who  has  published  a  valuable  work  "  On  the 
Influence  of  Posture  on  tlie  Health  of  Women,"  considers 
that  the  erect  posture  has  much  influence  in  inducing  dis- 
ease, gravitation  giving  rise  to  vascularity.  He  considers 
the  sitting  posture  on  a  chair  as  unnatural  and  injurious, 


I  86  DISEASES   OF   WOMEN. 

and  would  prefer  the  sitting  posture  on  the  floor.  It  is  in 
accordance  also  with  my  experience  that  the  prolonged 
ordinary  sitting  posture  is  injurious,  and  I  have  seen  many 
cases  where  this  posture  could  not  be  borne  at  all.  But  I 
do  not  know  whether  sitting  on  the  floor  would  or  would 
not  prove  equally  inconvenient. 

Lawn-tennis  and  croquet,  when  carried  to  exce6S,  in  the 
case  of  individuals  predisposed  to  flexion,  are  not  free  from 
danger,  though  doubtless  innocent  enough  under  other  cir- 
cumstances. 

The  next  class  of  cases  includes  special  occupations  re- 
quiring much  standing.  Young  women  standing  for  many 
hours  consecutively  at  the  counter  become  frequently  af- 
fected with  flexion  of  the  uterus.  In  hospital  practice  sucli 
cases  not  uncommonly  present  themselves.  Dr.  Edis  has 
lately  done  good  service  in  calling  public  attention  to  tlie 
injurious  effects  resulting  from  such  over-standing:  the 
production  of  severe  flexion  of  the  uterus  is  certainly  one 
of  them. 

The  occupation  of  nursing,  involving,  as  it  does,  neces- 
sity for  lifting  invalids  or  for  standing  many  hours  togetiier, 
is  liable  to  cause  severe  flexions  in  the  case  of  young  women 
who  are  not  strong  and  properly  trained  to  the  work. 
Numerous  instances  have  fallen  under  my  notice  in  which 
permanent  ill-health  or  incapacity,  due  to  a  severe  uterine 
flexion  produced  while  nursing  a  sick  relative,  has  been 
observed. 

Laundry  work  is  perhaps  one  of  the  most  trying  to  the 
attachments  and  connections  of  the  uterus.  It  is  liable  to 
produce  severe  flexion,  though  it  is  more  commonly  the 
case  that  actual  prolapsus  is  produced  by  excessive  labor  of 
this  kind.  The  use  of  the  sewing  machine,  playing  the 
harmonium,  or  organ,  are  other  occupations  requiring  men- 
tion. Some  severe  uterine  flexions  have  been  produced  by 
these  occupations  in  cases  which  have  come  under  my 
notice. 

Straining  in  defaecation  is  both  a  consequence  and  a  cause 
of  uterine  flexion.  Nothing  is  more  common  tlian  to  meet 
with  cases  in  which  uterine  displacement  and  flexion  give 
rise  to  constipation.  The  effort  required  to  relieve  the 
bowel  increases  the  existing  flexion.  This  is  more  particu- 
larly the  case  in  retroflexion.  I  have  seen  a  case  of  retro- 
flexion in  which  the  fundus  uteri  was  driven  downward  by 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    187 

the  straining  effort  against  the  sphincter  ani,  most  effectively 
blocking  up  the  canal  like  a  ball-valve. 

Marriage  must  be  mentioned  among  the  causes  of  flexion. 
In  cases  where  there  is  a  predisposition  to  flexion,  and 
where  the  uterus  is  soft  and  weak,  intercourse  has  often  a 
very  prejudicial  effect;  and  marriage  in  such  cases  may 
lead  to  troublesome  disease  of  the  uterus  in  consequence  of 
the  mechanical  disturbing  influence  thereby  brought  to 
bear  upon  it. 

It  seems  probable  that  were  the  true  history  of  every 
individual  case  known  the  cause  would  be  evident  enough. 
I  have  found  it  possible  to  assign  a  cause  in  a  very  large 
percentage  of  the  cases  which  have  come  under  my  notice, 
and  frequently  the  cause  has  been  discovered  some  time 
after  the  patient  has  been  under  treatment.  Slight  acci- 
dents, even  severe  ones,  are  often  passed  unnoticed.  In 
many  cases,  no  doubt,  the  flexion  occurs  gradually.  There 
is  generally  in  such  cases  a  slight  predisposition  to  begin 
with;  and  although  the  exertion  or  exercise  taken  by  the 
patient  is  nothing  out  of  the  ordinary,  it  is  more  than  can 
be  endured;  and  in  the  end,  after  many  years  perhaps,  the 
uterus  is  found  affected  with  a  severe  form  of  flexion. 
Young  women,  imperfectly  fed,  having  no  stamina  to  begin 
with,  and  called  upon  to  undertake  duties  involving  stand- 
ing or  walking  or  other  exertion — governesses,  for  instance, 
called  upon  to  daily  take  long  walks  with  their  more  robust 
pupils — offer  numerous  instances  of  the  truth  of  these 
remarks. 


DISEASES   OF   WOMEN. 


CHAPTER  XVI. 

Displacements  and  Distortions  of  the  Uterus  (Flex- 
ions)— 4.  Classification  and  Pathological  Effects. 

Classification  of  Flexions  and  consequent  Displacements. — Patho- 
logical Effects. 

I.  The  Seat  of  the  Flexion.  2.  Variations  in  the  Condition  of  the  Tissues 
of  the  Uterus.  3.  Various  Kinds  of  Flexion  or  Version  (Rotation). 
4.   Varieties  in  Position  of  Uterus  as  a  whole. 

Pathological  Effects  of  Flexions,  Relation  to  Congestion,  Relation 
to  Hypertrophy  of  the  Uterus — Contraction  of  the  Cervical  Canal — 
Changes  in  the  Uterus,  Atrophy,  Compression  at  the  Seat  of  the  Bend, 
Sensitiveness  at  the  latter  Spot — Persistence  of  the  Distorted  Shape  of 
the  Uterus — Changes  at  the  Os  Uteri. 

One  principal  cause  of  disagreement  in  regard  to  flexion 
of  the  uterus  is  want  of  appreciation  of  the  fact  that  flex- 
ions vary  so  much  in  character  in  different  cases.  To  over- 
come this  initial  difficulty  it  is  necessary  to  attempt  some 
classification  of  the  varieties  observed. 

classification   of    flexions  of  the    uterus  and  conse- 
quent   DISPLACEMENTS. 

1.  The  Seat  of  the  Bend. — The  most  common  situation  is 
the  position  of  the  internal  os  uteri,  or  about  midway  be- 
tween the  OS  uteri  externum  and  the  top  of  the  fundus. 
Dr.  Emmet,  speaking  particularly  of  anteflexions,  adopts  a 
peculiar  classification.  He  speaks  of  (i)  flexions  of  the 
cervix  below  the  vaginal  junction,  and  of  (2)  flexion  of  the 
body  of  the  uterus.  He  regards  the  first  as  congenital,  the 
second  as  liable  to  occur  after  puberty.  I  do  not  share  his 
view  as  to  the  congenital  nature  of  the  first  variety,  but  it 
is  the  fact  that  the  greater  part  of  the  bend  is  low  down  in 
many  cases.  In  most  cases  the  bend  affects  a  consider- 
able part  of  the  uterine  canal,  involving  the  upper  part  of 
the  cervix  as  well  as  the  lower  part  of  the  body  of  the 
uterus. 

2.  Variation  in  the  Condition  of  the  Tissues  of  the  Uterus 
associated  with  the  flexion.  This  variation  is  very  impor- 
tant in  the  classification  of  flexions. 

a.  The  uterus  may  be  excessively  soft,  hardly  more  re- 
sistant than  wet  brown  paper.     Reduction  of  the  flexion 


DISPLACEMENTS,   DISTORTIONS   OF   THE    UTERUS.    189 

easy,  but  recurrence  not  observed  perhaps  until  patient  has 
moved  about  again. 

b.  Moderately  soft,  hypertrophied  as  regards  the  fundus 
and  cervix,  congested  and  heavy.  Reduction  easy,  recur- 
rence on  withdrawal  of  sound  not  immediate. 

c.  Normally  hard,  but  hypertrophied  as  regards  the  fun- 
dus and  cervix — one  or  both.  Reduction  difficult,  recur- 
rence on  withdrawal  of  sound  immediate. 

d.  Excessively  hard,  the  os  perhaps  much  hypertrophied, 
lips  everted  and  congested;  much  hypertrophy  of  body  of 
uterus  also.  Reduction  very  difficult,  or  only  to  be  effected 
by  sustained  effort. 

e.  Variations  in  the  thickness  of  the  uterine  walls,  espe- 
cially at  the  seat  of  the  flexion. 

3.  Various  Kinds  of  Flexion  and  Version. — 

a.  Anteversion  (anterior  rotation)  pure  and  simple. 

b.  Anteflexion,  first  degree       )      -.^i  •       j 

J,         '  ,*,  f  with  varymg  degrees 

c.  second  degree  \    .       .     ■  .  .■ 

J  ,(  ♦111  (of  anterior  rotation. 

d.  third  degree      ) 

e.  Retroversion  (posterior  rotation)  pure  and  simple. 

/.  Retroflexion,  first  degree       )      •.,            •       j 

■'  u                         J  *^            f  with  varving  degrees 

p-.  second  degree  \    e        .'•..• 

*,  ,j               ^\  •  A  A                (of  posterior  rotation. 

//.  "               third  degree     )       ^ 

j.  Lateriflexion,  right  or  left. 

k.  Anteflexion  with  subsequent  posterior  rotation,  the 
uterus  yet  preserving  its  anterior  flexion. 

Oscillating,  or  alternate  ante-  and  retroflexion. 

There  are  more  minute  shades  of  difference  observable 
than  those  above  indicated,  and  the  differences  existing 
between  first,  second,  and  third  degrees  of  flexion  may  be 
not  easy  precisely  to  define,  but  in  practice  an  approximate 
definition  of  the  degree  of  flexion  present  is  generally  quite 
practicable. 

4.  Variation  in  Position  of  Uterus  as  a  whole. — 

a.  Uterus  pushed  backward  on  the  floor  of  the  pelvis, 
with  or  without  flexion  of  the  same.     (Not  common.) 

b.  Uterus  prolapsed,  more  or  less  completely  in  a  retro- 
flexed  state.  (This  condition  more  properly  comes  under 
the  head  of  "  Prolapsus.") 

c.  Uterus  higher  than  usual  in  the  pelvis,  but  in  a  flexed 
condition.     (Very  rare.) 

d.  Uterus  flexed  in  various  modes  and  degrees  (see  pre- 
ceding list),  and  lying  lower  than  usual  in  the  pelvis. 
(This  is  the  most  common  condition.) 


1 90 


DISEASES   OF   WOMEN. 


t 


r^ 


I  propose  in  the  next  place  to  call  attention   to  some  of 
the  pathological  effects  of  flexions  of  the  uterus.     Fig.  34 
represents  the  comparative   thickness  of  the  walls   of  the 
Fig.  34.  uterus,    as    shown    by   a    section 

through  it  vertically  and  from  be- 
fore backward.  What  would  be 
the  effect  upon  the  uterus  of  a 
bending  of  the  organ  ?  It  would 
obviously  be  to  produce  a  com- 
pression of  the  tissues  of  the  organ 
at  the  seat  of  the  bend  (Fig.  35). 
Such  compression  is  in  the  nature 
of  things  inevitable.  The  distance 
between  the  external  and  the  in- 
ternal wall  will,  in  process  of 
time,  though  probably  not  imme- 
diately, be  diminished.  The  dim- 
inution of  the  thickness  of  the 
walls  of  the  uterus  will  take  place 
to  a  greater  extent  on  the  concave 
side  of  the  bend.  There  will  be 
a  diminution  of  the  diameter  at 
the  position  of  the  flexion  {a,i>,c), 
and  the  general  result  will  be  that 
there  is  a  compressing  force  exer- 
cised at  the  middle  of  the  uterus 
upon  the  tissue  of  the  organ  (Fig. 
35).  The  effects  of  this  compression  in  retarding  the  circu- 
lation in  the  uterus,  and  in  producing  &cu\.e  congtstion  oi  the 
organ,  have  already  been  discussed  at  p.  112  in  connection 
with  the  subject  cf  congestion  of  the  uterus.  Its  effects  in 
producing  a  "strangulation"  of  the  uterus  have  been  also 
described  in  the  same  place.  It  is,  I  believe,  an  inevitable 
result  that  the  circulation  in  the  upper  part  of  the  uterus 
should  be  in  a  considerable  degree  interfered  with  when 
compression  is  thus  exercised  upon  the  uterus  and  its  ves- 
sels, the  result  being  that  the  upper  part  of  the  uterus 
comes  in  the  end  to  contain  a  larger  portion  of  blood  than 
usual.  It  becomes  unduly  heavy  and  larger.  It  becomes 
not  only  congested,  but  likewise  sensitive,  to  an  extraordi- 
nary degree  in  some  cases;  and  the  congestion  and  sensi- 
tiveness constitute  the  most  important  of  the  phenomena, 
to  a  less  degree  in  anteflexion  than  in  retroflexion.  This 
compression  in  the  middle  of  the  uterus  produces  variou? 


DISPLACEM'feNTS,   DISTORTIONS   OF   THE    UTERUS.    I9I 

effects  in  different  cases.  After  a  time,  if  the  flexion  is  not 
very  acute  in  degree,  the  uterus  may  become  habituated  to 
it,  and  acquire  a  certain  toleration  of  tliis  condition.  But 
wiien  it  does  not  acquire  the  toleration,  or  when,  as  fre- 
quently happens,  the  malady  increases,  we  have  an  oppor- 
tunity of  witnessing  the  following  effects:  the  fundus  uteri 
is  found  sensitive,  swollen,  and  tender  on  pressure*  the  pa- 
tient is  in  a  state  of  discomfort  which  hardly  any  physical 
condition  of  other  organs  of  the  body  can  exceed.  The 
physical  compression  of  the  uterus  is  a  phenomenon  to 
which  I  attach  great  importance  as  a  feature  in  the  natural 

Fig.  35. 


history  of  these  cases.  An  important  effect  of  the  mechan- 
ical interference  with  the  circulation  in  the  uterus  occurring 
in  connecticm  with  flexion,  is  that  produced  upon  the  men- 
strual functions.  One  effect  of  flexion  is  to  narrow  the 
uterine  outlet  so  that  the  menstrual  products  do  not  so 
readily  escape.  But  chronic  congestion  due  to  flexion  alters 
the  menstrual  discharge  in  another  way.  Sometimes  the 
quantity  is  enormously  increased.  In  other  cases  it  is  as 
much  diminished,  is  scanty  and  very  trifling  in  amount. 
It  is  not  uncommon  to  find  cases  in  single  women  where 
menstruation  has  for  some  time  been  profuse,  and  then  has 
become  altogether  too  scanty.  These  results  are  due  to 
mechanical  interference  with  the  general  uterine  circulation 
which  severe  flexion  is  capable  of  producing. 

The   next  effect  to   be   mentioned    is   hypertrophy  of  the 


192  DISEASES   OF  WOMEN. 

uterus^  general  enlargement  of  the  organ,  the  result  of  long- 
continued  congestion.  Dr.  John  Williams  considers  that 
the  hypertrophy  observed  in  cases  of  flexion  is  analogous 
to  the  hypertrophy  of  the  heart  due  to  stenosis  of  the  ori- 
fices. In  connection  with  the  subject  of  hypertrophy  of  the 
uterus,  it  is  necessary  to  consider  the  influence  of  defective 
involution  after  delivery.  When  we  have  the  two  things 
associated  together — defective  involution  and  flexion — we 
find  hypertrophy  of  the  whole  organ.  Flexion  alone  is 
sufficient,  but,  when  co-t)perating  with  defective  involution, 
the  hypertrophy  is  most  marked.  Further,  associated  with 
tiiis  hypertrophy  of  the  cervix  of  the  uterus,  we  generally 
meet  with  the  following  conditions:  A  very  great  increase 
of  secretion  from  the  cervical  glands,  and  other  changes  in 
the  mucous  membrane  which  were  formerly  considered  to 
be  ulcerative  in  character. 

Descent  of  the  Uterus  as  a  Whole. — A  common  effect  of 
flexion  is  descent  of  the  uterus  as  a  whole.  This  is  one  of 
tlie  most  important  effects,  clinically,  and  is  the  starting- 
point,  in  many  cases,  of  prolapsus  of  the  uterus.  It  is  the 
first  step  in  the  process  in  a  considerable  number  of  cases. 
When  the  uterus  is  flexed,  it  becomes  from  that  moment  a 
source  of  irritation;  the  patient  has  difficulty  in  evacuating 
the  contents  of  the  rectum,  and  the  functions  of  the  bladder 
are  interfered  with,  though  in  a  somewhat  different  manner. 
The  general  result  is,  that  the  patient  has  frequently  to 
use  straining  efforts  either  at  stool  or  in  micturition.  The 
effect  of  this  straining  is  to  propel  the  uterus  downward 
in  the  pelvis;  and  when  this  process  has  been  going  on  for 
weeks  and  for  months,  or  for  5'ears,  the  result  is  eventuall}'^ 
that  the  uterus,  as  a  whole,  comes  to  occupy  a  position  in 
the  pelvis  which  is  much  lower  than  it  should  be.  In  mak- 
ing an  examination,  we  find  the  os  uteri  quite  close  to  the 
vaginal  ap:>erture  in  many  instances;  or,  if  we  do  not  find  it 
there,  we  find  it  dislocated  in  a  corresponding  manner  back- 
ward, and  very  low  down.  I  believe  this  is  the  mechanism 
of  the  first  stage  of  prolapsus  of  the  uterus  in  nine  cases  out 
of  ten. 

The  mechanical  results  observed  are  very  interesting,  and 
will  be  more  particularly  described  in  the  chapter  on  Pro- 
lapsus. 

Compression  and  contraction  of  the  cervical  canal  is  another 
very  important  effect  of  flexion.  It  is  necessary  that  this 
canal  should  be  in  a  patent  condition,  in  order  that  menstru- 


Displacements,  distortions  of  the  uterus.  193 

ation  may  occur  easily,  and  that  impregnation  may  take 
place.  Contraction  of  the  cervical  canal  is  one  of  the  com- 
mon causes  of  dysmenorrhoea  and  of  sterility,  and  is,  ac- 
cording to  my  experience,  a  direct  and  almost  necessary 
effect  of  fle.xion  of  the  uterus  (see  chapters  on  Anteflexion 
and  Dysmenorrhoea).  Other  conditions  may  produce 
contraction  of  the  canal,  but  the  percentage  of  cases  of  con- 
traction due  to  other  causes  is  not  more  than  from  one  to 
three  or  four  per  cent.  The  mechanism  by  which  flexion 
obstructs  is  obvious.     At  the   internal  os  uteri,  the  canal 

Fig.  36.* 


'rTT:^iii;A''iy-/' 


has  a  diameter,  under  ordinary  circumstances,  of  one  eighth 
of  an  inch;  tlie  canal  is  larger  below  that  point.  But  as  the 
strength  of  a  chain  is  that.of  its  weakest  link,  so  the  size  of 
a  canal  is  that  of  its  smallest  portion,  when  we  come  to 
consider  how  far  it  is  available  for  the  passage  of  fluid. 
Regarding  the  thickness  of  the  walls,  in  proportion  to  the 

*  Fig.  36  represents  a  case  of  long-standing  retroflexion  of  the  uterus. 
For  purposes  of  illustration,  I  have,  in  teaching,  used  a  model  of  the 
uterus  on  a  large  scale,  constructed  from  sponge.  When  this  model 
uterus  is  acutely  bent,  the  compression  thereby  produced  at  the  seat  of 
the  bend  is  very  obvious.  A  marked  condensation  occurs  at  this  spot.  [The 
vagina  is  here  represented  by  the  artist  as  it  should  be  in  anteflexion. 
It  should  run  in  the  opposite  direction  to  make  it  a  retroflexion.] 


194^  •  DISEASES   OF   WOMEN. 

size  of  the  cervical  canal,  it  may  be  conceived  what  must 
happen  when  that  organ  is  bent  at  an  acute  angle;  viz.,  a 
very  considerable  narrowing  of  the  canal  (Figs.  35  and  36). 
This  is  the  explanation  of  dysmenorrhoea,  and  the  reason 
wh}'  it  occurs  so  frequently  in  cases  of  flexion.  In  cases 
where  the  flexion  takes  place  very  gradually,  where  it  has 
been  advancing  over  a  period  of  manyj'ears,  the  narrowing 
may  be  less  obvious,  owing  to  the  gradual  arching  of  the 
canal;  but  when  the  flexion  is  produced  suddenly  and 
acutely,  it  is  often  very  decided. 

In  some  cases  there  is  a  real  stricture  at  or  near  the  in- 
ternal OS  uteri,  and  the  canal  ^at  the  place  in  question  is 
really  narrow,  and  the  sound  only  passes  through  the  nar- 
rower part  with  a  kind  of  jerk;  but  in  many  cases  there  is 
only  what  may  be  termed  a  potential  stricture.  The  canal 
is  narrowed  and  obstructed  by  the  forcible  coaptation  of 
the  opposite  walls;  thus  the  passage  of  fluids  through  it  is 
obstructed,  although  the  sound,  if  gently  introduced,  may 
be  easily  made  to  traverse  the  apparently  narrowed  part  of 
the  canal.  There  have  been  very  great  differences  of 
opinion  as  to  the  frequency  of  stricture  of  the  internal  os, 
but,  according  to  my  experience,  actual  stricture  of  the  in- 
ternal OS  is  not  verj-  common;  while,  on  the  other  hand, 
apparent  obstruction  is  frequently  observed  in  cases  of 
acute  flexion.  The  condition  of  the  uterus  as  regards  hard- 
ness and  softness  is  very  important  in  the  true  estimation 
of  these  cases,  for  when  the  uterus  is  very  soft  the  sound 
may  pass  in  quite  readily  if  held  rather  stiffly,  and  I  have 
known  cases  where  severe  flexions  have  been  overlooked, 
apparently  from  this  circumstance  of  the  sound  encounter- 
ing no  obstruction  and  thus  entering  in  what  seemed  to  be 
the  normal  manner.  The  fact  is,  that  in  such  cases  the 
sound  straightened  the  uterus  as  it  entered. 

The  uterine  canal  being  more  or  less  impermeable  in 
consequence  of  the  flexion,  various  other  effects  result:  such 
as  the  retention  of  fluid  in  utero,  dysmenorrhoea  from  re- 
tention, leucorrhcea  from  retention,  and  sterility.  Further 
remarks  on  these  subjects  will  be  found  in  the  several 
chapters  relating  to  them. 

The  effect  on  the  walls  of  the  uterus  at  the  seat  of  the 
flexion. — At  the  place  where  the  flexion  occurs,  generally  at 
the  OS  internum,  certain  effects  and  changes  are  produced. 
It  appears  that  one  of  the  first  effects  of  the  flexion  is  to  give 
rise  to  a  swelling  of  the  tissues  of  the  uterus  on  the  concave 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    I95 

side  of  the  bend,  this  swelling  affecting  the  uterine  tissue 
and  the  plexus  of  vessels  just  outside  the  uterus.  There  is 
a  specimen  in  the  Middlesex  Hospital  Museum,  in  which  a 
section  shows  an  increase  of  the  thickness  of  the  wall  of 
the  uterus  on  the  concave  side  of  the  flexion.  In  some 
cases  of  antefle.xion  I  have  observed  the  presence  of  a  sort 
of  transverse  ridge  or  elevation  projecting  on  the  concave 
aspect  of  the  uterus,  and  felt  by  the  finger  through  the 
roof  of  the  vagina,  due,  no  doubt,  to  the  swelling  of  the 
tissues  as  above  described.  This  is  a  condition  of  thinqs 
which  is,  however,  not  generally  met  with  when  the  flexion 
has  existed  any  considerable  time.  After  two  or  three 
years  (in  cases  of  acute  flexion)  there  always  occurs  an 
atrophy  of  the  uterine  wall  on  the  concave  side  of  the  bend, 
and  a  consequent  thinning  of  the  wall  at  that  spot.  I 
have  found  it  apparently  hardly  thicker  than  a  piece  of 
cartridge-paper  at  this  spot.  This  condition  of  the  uterine 
wall  was  some  years  ago  described  by  Virchow.  It  appears 
to  be  a  physical  result  of  the  compression  or  squeezing  of 
the  uterus  itself  at  this  situation.  And  it  is  not  observed 
unless  the  flexion  is  severe  enough  in  degree  to  cause  such 
a  compression.  Accompanying  irtrophy  of  the  uterine  wall 
as  here  described,  there  often  occurs  a  considerable  degree 
of  hardening  or  condensation  of  the  tissues.  Probably  the 
condensation  is  first  in  order  of  occurrence,  the  atrophy 
occurring  later  on.  In  cases  where  this  hardening  occurs, 
the  uterine  sound,  on  passing  the  narrowed  part,  encounters 
considerable  resistance,  and  passes  through  and  beyond  it 
with  a  kind  of  jerk.  In  some  cases  the  compressed  tissues 
are  actually  softened. 

The  compression  to  which  the  uterine  tissues  are  sub- 
jected at  the  seat  of  the  bend  has  the  result,  in  many 
cases,  of  producing  an  extreme  sensitiveness  to  the 
touch  at  the  point  in  question.  This  is  evident  on  using 
the  sound.  Thus,  it  will  be  found  that  the  sound  enters 
the  cervical  canal  easily  and  gives  no  pain,  but  when  it 
touches  the  uterine  canal  at  about  the  internal  os,  severe 
pain  is  felt  and  evidence  given  of  the  existence  of  great 
sensitiveness.  Passing  beyond  this  point  into  the  uterine 
cavity,  it  is  found  that  the  pain  ceases.  This  observation 
I  have  made  in  several  such  cases.  It  is  principally  observ- 
able in  those  cases  where  the  flexion  is  of  long  standing. 
The  conclusion  which  I  have  formed  as  to  such  cases  is, 
that  the  uterine  nerves  distributed  to  the  tissues  which  are 


196  DISEASES  OE  WOMEN. 

the  seat  of  the  compression  are  irritated  by  it,  and  that 
this  is  the  explanation  of  the  tenderness  to  the  touch.  The 
remarkable  immunity  from  tenderness  above  and  below  the 
part  affected,  and  its  precise  agreement  in  position  with 
that  of  the  bend,  have  led  me  to  adopt  the  above  explana- 
tion. This  conclusion  is  of  great  interest  in  reference  to 
various  important  questions  as  to  the  nervous  and  hysteri- 
cal affections  to  which  women  are  liable. 

Slight  bending  of  the  uterus  is  not  liable  to  produce 
atrophy  of  the  walls  at  the  seat  of  flexion.  Atrophy  occurs 
to  the  greatest  degree  in  cases  where  the  flexion  is  acute, 
and  of  long  standing. 

Chronicity  of  severe  flexion  of  the  uterus  appears  to  be 
mainly  connected  with  alterations  in  the  thickness  of  the 
w^all  at  the  seat  of  flexion. 

This  leads  me  to  speak  of  the  persistency  of  the  distorted 
shape  in  cases  of  flexion.  This  persistency  varies  exceed- 
ingly in  different  cases,  and  appears  to  depend  on  the  fol- 
lowing circumstances:  If  the  flexion  be  severe,  and  nothing 
be  done  to  relieve  it  the  uterus  becomes  hardened,  literally, 
in  its  distorted  shape.  This  is  observed  when  the  flexion  is 
the  result  of  a  severe  accident,  the  individual  being  in  a 
state  of  health  at  the  time. 

Changes  at  the  Os  Uteri. — Another  effect  often  observed  in 
chronic  flexion  is  eversion  of  the  cervical  canal,  so  that  the 
OS  uteri  presents  a  raw,  vascular  surface.  Such  a  condition 
is  particularly  met  with  (1)  in  cases  of  single  women,  where 
the  uterus  has  become  hypertrophied,  softened,  and  the  os 
considerably  increased  in  size;  or  (2)  in  cases  where  the 
patient  has  borne  children,  and  the  aperture  of  the  os  is 
wide  from  side  to  side.  The  eversion  most  affects  the  pos- 
terior wall  of  the  cervical  canal  in  cases  of  retroflexion, 
and  the  anterior  wall  of  the  canal  in  cases  of  anteflexion. 
If  the  cervix  has  been  lacerated  bilaterally,  the  degree  of 
eversion — ectropion — is  very  great.  Such  laceration  of  the 
cervix  is  not  very  uncommon,  as  has  been  pointed  out  by 
Dr.  Emmet  of  New  York.  Eversion  may,  however,  occur 
quite  apart  from  laceration  of  the  cervix. 


DISPLACEMENTS,  DlStORTlONS  OF  THE  UTERUS.   I97 


CHAPTER  XVn. 

Displacements  and  Distortions  of  the  Uterus  (Flex- 
ions)— 5.  Symptoms,  Including  Sterility  and  Abor- 
tions. 

Pain,  Spontaneous — Pain  on  Locomotion  (Uterine  Dyskinesia) — Ex- 
planation of  this  Symptom:  its  great  Importance — Undue  Tenderness 
of  the  Uterus  to  Touch — The  "Irritable  Uterus"  of  Gooch  shown  to 
be  Acute  Flexion. 

Dysmenorrhoea,  Leucorrhoea,  Menorrhagia,  Amenorrhoea — Sterility — 
Abortions — Statistics  of  Sterility  and  Abortions  in  Hospital  and  Pri- 
vate Practice. 

Disturbance  of  Functions  of  Bladder — of  Rectum — Dyspareunia — Reflex 
Nervous  Symptoms. 

There  is  abundant  clinical  evidence  to  show  that  of  all 
the  various  derangements  of  function,  observable  in  dis- 
eases of  the  uterus,  by  far  the  larger  proportion  are  trace- 
able to  the  existence  of  flexions  of  the  uterus  or  to  tiie 
secondary  effects  of  these  flexions.  In  a  former  chapter 
(see  p.  92)  a  list  was  given  of  the  various  symptoms  ob- 
served in  practice.  It  will  now  be  necessary  to  take  these 
symptoms  one  by  one  and  point  out  how  far  they  are  con- 
nected with  the  existence  of  uterine  flexions. 

Pain  is  either  (i)  spontaneous — occurring,  that  is  to  say, 
when  the  patient  is  at  rest;  or  (2)  //  is  produced  by  motion  of 
the  body  or  exertion;  or  (3)  it  is  produced  by  touching  the 
uterus  itself — abnormal  sensitiveness. 

Spontaneous  Pain. — It  is  not  common  to  meet  with  severe 
spontaneous  pain  in  cases  of  flexion  of  the  uterus  when  the 
patient  is  completely  at  rest.  It  is  not  uncommon  to  meet 
with  a  continuous  slight  aching.  Spasmodic  pain  is  not 
very  uncommon.  It  has  been  described  under  the  name 
uterine  colic — a  pain  coming  suddenly,  lasting  a  short  time, 
and  disappearing  for  a  distinct  interval,  resembling,  in 
fact,  very  much  a  miniature  labor  pain.  Such  spasmodic 
pains  are  now  and  then  met  with  in  cases  of  uterine  flexion. 
In  a  few  cases  a  fixed  pain  is  observable  even  when  the 
patient  is  at  rest. 

It  varies  also  according  to  the  nature  of  the  flexi»n.  As 
a  rule,  anteflexion  is  indicated  by  one  kind  of  pain,  and 
retroflexion  by  another.     But  these  rules  are  open  to   ex- 


19§ 


DISEASES  OF  WOMEN. 


ception.  Most  commonly  the  pain  is  felt  in  the  back,  in 
the  sacral  region.  Another  frequent  position  for  pain  is 
one  of  the  groins,  just  above  Poupart's  ligament,  on  one  or 
the  other  side.  It  is  sometimes  felt  in  the  region  of  the 
uterus  itself,  but  this  is  not  so  common.  It  is  rather  com- 
mon for  it  to  be  experienced  down  the  back  of  the  legs, 
down  the  back  of  the  thighs,  on  one  side  or  the  other. 
With  retroflexion  the  pain  most  commonh*  occurs  in  the 
back,  with  anteflexion  in  the  inguinal  regions;  in  different 
cases,  however,  we  find  very  remarkable  variations  in  these 
rules. 

Some  years  ago  I  was  requested  to  see  a  young  lady  who 
had  been  affected  with  pains  in  one  spot  in  the  abdomen, 
just  on  a  level  with  the  umbilicus,  and  on  tlie  left  side  of  it; 
she  had  not  been  without  that  pain  for  a  period  of  five  or  six 
months,  and  she  had,  previously  to  this  time,  for  some  years 
experienced  other  pains  and  serious  discomforts.  But  the 
particular  circumstance  to  which  she  called  my  attention 
was  this  pain  in  the  abdominal  region,  in  the  position  indi- 
cated. No  tumor  could  be  discovered  in  the  abdomen,  nor 
was  there  any  apparent  cause  for  this  pain.  But  on  investi- 
gating the  condition  of  the  uterus,  it  was  found  that  the 
patient  was  the  subject  of  acute  retroflexion.  The  case  was 
additionally  interesting  from  the  fact  that  after  the  intro- 
duction of  the  sound  into  the  uterus,  and  turning  the  uterus 
into  its  proper  position,  there  w^as  no  return  of  the  pain 
whatever.  Further  treatment  w^as  necessary  to  rectify  the 
state  of  the  uterus;  but,  this  particular  pain,  which  was  a 
source  of  so  much  annoyance,  went  away  after  the  first  use  of 
the  sound.  Another  case,  equally  interesting,  was  that  of 
a  lady  who  had  had  one  child  about  five  years  previous  to 
the  time  of  my  seeing  her.  She  had  been  unable  to  walk 
about  or  to  follow  her  ordinary  avocations  since  the  labor; 
but  the  inconvenience  of  which  she  chiefly  complained  was 
a  pain  on  the  right  side  of  the  abdomen,  on  a  level  with  the 
umbilicus,  and,  in  fact,  in  a  corresponding  position  to  the 
pain  in  the  first  case  mentioned.  This  patient  was  found 
on  investigation  to  have  acute  retroflexion  of  the  uterus. 

I  mention  these  exceptional  cases,  because  they  illustrate 
the  fact  that  the  pain  which  is  produced  by  flexion  of  the 
uterus  is  not  always  in  the  same  position.  More  generally, 
in  90  per  cent  of  cases,  the  rule  holds  good  that  the  pain  is 
located  in  the  back  in  cases  of  retroflexion,  and  in  the  ingu- 
inal regions  in  cases  of  anteflexion.     As  a  rule,  patients  do 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    tQQ 

not  complain  of  pains,  in  cases  of  flexion,  so  long  as  they 
remain  quiet.  If  tlie\'  remain  in  bed,  or  are  content  to  lie 
on  tlie  sofa,  there  is  usually  but  little  pain.  But  any  de- 
gree of  motion  is  sufficient,  or  may  be  sufficient,  to  bring 
on  pain,  and  the  pain  that  is  thus  brouglit  on  may  be  either 
severe  in  degree  or  comparatively  trifling;  in  some  instances 
the  discomfort  produced  can  hardly  be  said  to  amount  to 
pain. 

Pain  on  Locomotion  (  Uterine  Dyskinesia). — This  is  one  of  tlie 
very  commonest  of  the  symptoms  observed  in  cases  of  uter- 
ine flexion.  It  is  a  symptom  to  which  no  sufficient  amount 
of  attention  has  as  yet  been  paid,  and  it  is  so  important  in 
its  effects,  that  careful  consideration  of  the  connection  as 
effect  and  cause  between  it  and  uterine  flexions  is  absolutely 
necessary. 

In  patients  suffering  from  flexions  the  pain  produced  by 
locomotion  varies  in  degree  very  much.  It  varies  from  a 
slight  pain  in  the  back  to  a  complete  inability  to  walk  or 
move  without  the  extremest  suffering.  Questioning  pa- 
tients as  to  their  sensations,  it  will  be  found  that  they  are 
almost  invariably  such  as  would  come  under  the  above 
heading — uterine  dyskinesia. 

The  pain  produced  by  locomotion  ma}'  be  slight  or  it 
may  be  violent  in  degree,  but  the  characteristic  of  it  is  that 
it  is  brought  on  by  motion.  It  may  be  so  severe  that  the 
l^aiient  is  practically  unable  to  move  at  all,  or  it  may  be  so 
slight  that  she  moves  in  spite  of  it,  and  continues  to  do  so. 
There  is  no  paralysis,  in  the  ordinarj'  sense  of  the  word, 
but  there  is  a  strong  disinclination  to  move.  The  degree 
of  disability  varies  exceedingly  in  different  cases.  Some 
patients  do  not  mention  it  unless  they  are  asked  whether 
they  can  take  a  moderate  walk,  without  suffering  pain; 
others  can  talk  of  nothing  else — the  inability  to  do  this, 
that,  or  the  other,  to  walk,  or  to  ride,  or  to  visit — these  are 
to  them  ever-present  evils  from  which  they  desire  deliver- 
ance. The  patient  informs  us  that  she  is  unable  to  stand 
fur  more  than  two  or  three  minutes  at  a  time,  after  which 
she  is  obliged  to  sit  down.  Such  patients  cannot  even  bear 
to  be  kept  waiting  at  the  door  while  the  bell  is  being  an- 
swered. Others  find  that  walking  a  short  distance  brings 
on  so  much  pain  and  produces  such  discomfort  that  exer- 
cise is  impossible.  It  is  a  remarkable  feature  that  in  all 
these  cases  motion  produces  pain.     Such,  for  instance,  as 


206  DISEASES   OF  WOMEN. 

Stooping  down  to  pick  up  any  object  from  the  floor,  lean- 
ing forv\'ard,  reaching  upward,  going  upstairs,  etc. 

The  disability  is  sometimes  so  great  that  the  patient  is 
shut  off  from  most  of  the  enjoyments  of  life,  for  the  simple 
reason  that  locomotion  is  impracticable.  Patients  consult 
us  for  a  variety  of  reasons.  In  many  cases  undoubtedly  the 
locomotive  disability  is  not  the  reason  they  assign  for  ap- 
plying for  relief.  In  a  vast  number  of  cases,  however,  this 
is  the  reason  impelling  them  to  seek  aid,  although  they 
have  not  formulated  their  ideas  on  the  subject  with  any  de- 
gree of  precision. 

The  significance  of  this  symptom  has  been  overlooked, 
partly  because  it  is  so  common,  partly  also  because  the  idea 
has  been  too  frequently  entertained  that  this  disinclination 
for  walking,  and  other  kinds  of  exertion,  is  a  fanciful  one — 
that  it  should  not  be  treated  seriously,  being  a  whim  or 
caprice  of  the  patient,  which  should  not  be  encouraged. 

In  sixty-seven  cases  of  uterine  distortion  or  displacement, 
admitted  during  seven  years  into  All  Saints'  Institution,  re- 
ported by  me  in  a  paper  read  to  the  Obstetrical  Society  of 
London,*  this  symptom  was  so  frequently  observed  that  it 
may  be  said  that  almost  all  the  sixty-seven  patients  pre- 
sented it  in  a  marked  form.  The  following  are  quotations 
from  the  paper  in  question: 

"  The  maladies  with  which  these  sixty-seven  patients 
were  affected  existed  in  various  degrees  of  intensity.  In 
several  cases  the  patients  were  actually  bedridden,  in  others 
the  capacity  for  locomotion  was  so  materially  diminished 
that  the  sufferers  had  to  give  up  their  emplo3'ment.  In 
other  cases,  again,  the  malady,  though  not  so  severe,  had 
proved  intractable,  and  therefore  relief  was  sought  in  the 
institution." 

"  Outwardly,  the  condition  of  these  patients  was  charac- 
terized by  great  weakness,  more  or  less  inability  to  walk 
(uterine  dyskinesia),  and  a  general  condition  of  malnutri- 
tion. The  principal  organ  aft'ected  was  the  uterus;  various 
degrees  and  forms  of  uterine  distortion  and  displacement 
existed,  causing  painful  symptoms  of  various  kinds;  pain 
on  locomotion,  nausea,  and  menstrual  irregularities  being 
those  principally  spoken  of." 

"Almost  all  the  sixty-seven  patients  admitted  into  the 
Institution  and  comprised   in  the  foregoing  remarks  pre- 

*  "  Obst.  Trans.,"  vol.  xxii.  for  iSSo. 


DISPLACEMENTS,   DISTORTIONS   OF  THE    UTERUS.   201 

sented  this  symptom  in  a  marked  form.  It  may  almost  be 
said  that  this  was  indeed  the  principal  symptom,  and  the 
one  which  had  forced  itself  on  their  particular  attention  in 
the  majority.  This  symptom  I  regard  indeed  as  one  de- 
serving of  attentive  notice  in  all  cases  of  uterine  distortion 
and  displacement.  The  fact  appears  to  be  that  physical 
exertion,  of  almost  any  kind,  is,  under  such  circumstances, 
uncomfortable  in  various  ways,  because  it  involves  an  ex- 
aggeration or  temporary  increase  of  the  malady  from  which 
the  patient  suffers.  An  active  life  is  necessarily  abandoned 
after  a  time  by  the  sufferer,  and  a  helpless  invalidism  is  the 
result  in  protracted  cases.  Some  of  the  patients  treated  in 
All  Saints'  Institution  had  been  bedridden  for  several  years. 
With  reference  to  such  cases,  it  must  be  further  remarked 
that  the  affection,  which  is  indeed  a  very  real  one  in  these 
instances,  is  one  which  it  was  formerly  the  custom  to  re- 
gard as  imaginary,  fanciful,  or  hysterical,  and  such  patients 
were  consequently  deprived  not  only  of  medical  help,  from 
the  fact  that  their  cases  were  misunderstood,  but  of  tiie 
sympathy  of  their  friends,  who  regarded  them  as  capable 
of  exertion  if  '  they  only  made  an  effort.'  The  fact  is,  that 
in  these  cases  exertion  only  aggravates  the  mischief  and 
perpetuates  the  malady." 

That  uterine  displacements  are  attended  with  discomforts 
is  not  a  new  idea.  Because  they  are  not  absolutely  univer- 
sally attended  with  discomforts,  certain  writers  have  thought 
themselves  justified  in  saying  that  uterine  displacements 
are  in  themselves  of  no  particular  importance.  But,  obvi- 
ously, the  correct  method  of  arriving  at  the  truth  on  this 
subject  would  be  to  inquire  how  far  and  how  frequently 
discomforts  referable  to  the  uterus,  such  as  the  particular 
one  now  under  consideration — namely,  impaired  locomo- 
tion, or  pain  produced  by  locomotion — can  be  proved  to  be 
connected  with  uterine  distortion  and  displacement.  The 
two  following  propositions  are  essentially  different,  as  will 
be  readily  admitted  when  they  are  concisely  stated:  i. 
Uterine  distortions  and  displacement  invariably  give  rise  to 
pain  on  locomotion.  2.  Pain  on  locomotion  of  such  a  kind 
as  to  be  referable  to  the  uterus  is  invariably  associated  with 
the  presence  of  uterine  distortion  or  displacement.  These 
propositions  are  not  identical,  nor  are  they  equally  true. 
Tlie  first  proposition  is  more  nearly  true  than  is  generally 
imagined.     The  second  is,  however,  according  to  my  ex- 


202  DISEASES   OF   WOMEN. 

perlence,  almost  absolutely  true,  and  this  is  the  particular 
point  to  wliich  attention  is  now  directed. 

The  connection  between  uterine  distortion  and  pain  on 
locomotion  has  attracted  little  attention  at  the  hands  of 
previous  writers.  To  this  statement  a  noteworth}''  excep- 
tion must  be  made.  Chassaignac,  in  his  work  on  "  Clinical 
Operativ'e  Surgery,"  published  some  years  ago,*  in  speaking 
of  the  relation  subsisting  between  certain  morbid  condi- 
tions of  the  uterus  ("deviations")  and  the  pains  and  dis- 
comforts with  which  these  alterations  are  associated,  thus 
expresses  himself:  Question:  What  is  the  cause  (says 
Chassaignac)  of  the  "accidents  doloureux"  observed  in 
women  the  subjects  of  uterine  deviation?  Answer:  The 
"  ballottements"  which  the  deformed  or  displaced  uterus 
undergoes.  Thus  two  conditions,  the  deviation  and  the 
movement  impressed  on  the  organ,  must  be  conjoined  in 
order  that  the  pain  may  be  produced.  Further,  this  author 
goes  on  to  state  his  opinion  that  the  reason  a  particular 
deviation  gives  rise  to  pain  in  one  patient  and  not  in  another 
is,  that  the  baliottewent  is  in  some  wa}'  prevented.  Also  that 
relief  is  to  be  given  b}'  curing  the  deviation  or  by  prevent- 
ing the  ballotteviefit.  Hence,  he  says,  the  horizontal  position 
is  so  frequently  effective  in  abolishing  the  pain.  Hence, 
also,  the  good  effect  of  pessaries,  the  benefit  derived  in 
some  cases  from  hypogastric  bandages,  etc.  The  uterus  is 
thus  brought  to  a  state  of  rest.  It  is  thus  evident  that 
Chassaignac  recognized  clinically  the  connection  above  in- 
sisted on;  and  not  only  so,  he  explained  this  connection  by 
the  concussion  or  jarring  of  the  distorted  or  displaced 
uterus  which  motion  of  the  body  produces. 

Before  going  further,  it  is  necessary  to  deal  with  the  fact, 
or  supposed  fact,  that  in  some  cases  uterine  distortions  do, 
and  in  others  do  not,  give  rise  to  painful  sensations  during 
locomotion — a  circumstance  which  has  had  much  to  do  in 
lending  support  to  fallacious  views  on  this  subject.  When 
flexions  are  apparently  not  causing  particular  inconven- 
ience to  the  patient,  it  has  been  argued  that  the}-  are  not  in 
themselves  of  any  great  consequence.  The  facts  of  the 
case,  according  to  my  own  experience,  are  as  follows:  Of 
the  various  forms  of  uterine  deviation  it  appears  that  some 
are  more  liable  to  be  attended  with  pain  during  locomotion 

*  "  Traite  Clinique  et  Pratique  des  Operations  Cbirurgicales,"  vol.  ii, 
p.  926.     Paris,  1863. 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    203 

than  others.  Thus,  take  first  descent  of  the  uterus  as  a 
whole,  unaccompanied  by  alteration  of  shape — cases  of  pro- 
lapsus, as  they  are  termed.  Now,  it  is  the  fact  that  such 
cases  are  really  not  attended  with  so  much  pain  as  others 
to  be  mentioned  presently.  It  is  quite  true  that  when  the 
uterus  protrudes  externally  it  is  a  serious  evil,  attended 
with  grave  inconveniences;  but  when  it  falls  short  of  this, 
and  does  not  protrude  externally,  the  pain  experienced  may 
not  be  very  noteworthy.  And  I  have  been  surprised  in 
some  bad  cases  of  external  prolapse  to  find  patients  com- 
plaining comparatively  little  of  difficulty  in  locomotion. 
Movement  may  of  course  produce  in  such  cases  friction, 
irritation,  and  ulceration  of  the  exposed  organ,  but.  apart 
from  these  effects,  the  movement  itself  may  not  be  accom- 
panied with  particular  discomfort. 

The  next  form  of  uterine  deviation  is  version  of  the 
uterus  (rotation  on  the  transverse  axis),  the  organ  preserv- 
ing its  proper  shape  more  or  less  perfectly,  but  being  tilted 
backward,  forward,  or  laterally,  as  the  case  may  be.  Slight 
version  may  be  accompanied  with  comparatively  little  dis- 
comfort. In  cases  of  severe  version,  forward  or  backward, 
the  pain  produced  by  locomotion  is  generally  very  distress- 
ing. Cases  of  version  not  accompanied  with  flexion  are, 
as  before  stated,  not  in  themselves  very  common,  but  it  is 
not  very  uncommon  to  meet  with  cases  of  slight  version 
together  with  slight  flexion.  And  in  these  latter  cases  the 
discomforts  now  under  consideration  are  undoubtedly  less 
severe  than  in  those  next  to  be  considered. 

The  next  category  of  cases  is  that  in  which  there  is  de- 
cided distortion  of  the  uterus,  accompanied  with  a  certain 
degree  of  version.  It  is  in  this  class  of  cases  that  pain 
produced  by  locomotion  is  most  severe.  These  cases  furnish 
the  instances  of  marked  interference  with  locomotion,  and, 
with  few  exceptions,  this  condition  of  the  uterus  is  attended 
with  the  symptom  in  question  in  a  more  or  less  marked 
form.  And  I  do  not  hesitate  to  state  that  I  have  found  the 
condition  and  the  symptoms  associated  so  very  constantly, 
that  no  room  exists  in  my  mind  for  doubt  on  the  subject. 
Here  we  meet,  as  I  have  already  remarked,  with  opposing 
statements  as  to  the  value  and  frequency  of  the  association. 
Thus  one  statement  is  to  the  effect  that.it  is  common 
enough  to  meet  with  cases  of  flexion  in  which  there  is  no 
complaint  and  no  inconvenience  felt  whatever.  I  can  only 
say  that  such  cases  do  not,  at  all  events,  present  themselves 


204  DISEASES   OF   WOMEN. 

in  my  practice.  There  are  various  ways  of  accounting  for 
this  discrepancy  as  to  a  matter  of  fact. 

Cases  vary  ver}'  much  in  severity,  and  too  much  has  been 
expected  in  regard  to  uniformity  of  symptoms  when  the 
conditions  were  not  uniform.  There  is  a  great  difference, 
for  instance,  between  the  degrees  of  flexion  in  the  two 
cases  of  retroflexion  represented  in  Figs.  37  and  38;  and 
the  degree  of  the  flexion,  the  degree  to  which  the  uterus  as 
a  whole  is  sunk  in  the  pelvis,  produces  necessary  differ- 
ences in  the  severity  of  the  symptoms.  As  regards  this  par- 
ticular symptom,  pain  on  locomotion,  it  is  one  which  I  have 
hardly  ever  found  absent  when  the  uterus  is  actuall)'  dis- 
torted. This  symptom  is  plainly  of  importance,  but  it  is 
not  one  which  has  usually  been  thought  much  of,  and  may 
have  been  present  even  to  a  marked  degree  in  some  of  the 
cases,  when  flexion  is  said  to  have  caused  no  complaint  or 
inconvenience.  Another  circumstance  is  that,  when  the 
flexion  is  slight,  and  there  is  more  version  than  flexion,  the 
pain  and  inconvenience  may  be  slight  in  degree.  Further, 
it  must  be  borne  in  mind  that  the  flexed  uterus  is  not  always 
in  the  same  textural  condition.  Sometimes  it  is  much  con- 
gested; at  other  times  not  particularly  full  of  blood.  Dr. 
Braxton  Hicks  has  published  *  observations  on  retroflexion 
of  the  uterus,  and,  in  accounting  for  differences  of  opinion 
on  the  treatment  of  this  affection,  he  points  out  the  differ- 
ences observable  at  different  times  in  regard  to  the  state  of 
the  uterus,  as  accounting  for  these  diverse  opinions.  These 
remarks  of  Dr.  Hicks  meet,  for  the  most  part,  with  my 
concurrence.  The  congestion  or  engorgement  is,  no  doubt, 
a  condition  which  adds  very  much  to  the  discomfort  which 
a  flexion  produces;  and  in  a  case  where  it  happened  not  to 
be  present,  the  discomfort  observed  might  be  comparatively 
trilling.  Then,  again,  the  duration  of  the  flexion  is  a  mat- 
ter affecting  painfulness.  When  the  case  is  one  of  long 
standing,  the  uterus  acquires  in  some  cases  a  kind  of  tolera- 
tion of  it,  and  locomotion  perhaps  ceases  to  be  painful. 
But  even  in  these  cases  it  is  enough  to  scrutinize  the  pre- 
vious history  to  become  aware  of  facts  which  tell  directly 
against  the  notion  that  flexions  ever  occur  without  giving 
rise  to  very  decided  discomfort  and  inconvenience. 

In  the  cases  where  pain  is  produced  by  locomotion,  it  is 
generally  the   fact  that  various  positions  of  the  body  or 

*  British  Medical  Journal,  iSyy, 


DISPLACEMENTS,  DISTORTIONS   OF  THE   UTERUS.   20S 

Fig.  37  * 


Fig.  38. 


Figs.  37  and  38  represent  first  and  third  degrees  of  retroflexion. 


2o6  DISEASES  OF  WOMEN. 

certain  exertions  give  rise  also  to  pain.  Thus,  lifting  a 
weight,  carr)ang  a  weight,  stooping  to  pick  up  objects  from 
the  floor,  reaching  to  hang  up  an  article  of  dress,  riding  in 
a  carriage  in  an  ordinary  sitting  position,  riding  on  horse- 
back, even  sitting  up  to  dinner, — any  one  of  these  exertions, 
and  a  multitude  of  others  that  might  be  mentioned,  pro- 
duce pain  more  or  less  severe.  The  horizontal  position  is 
in  many  cases  the  only  one  in  which  the  patient  is  secure — 
and  sometimes  not  even  then — from  pain. 

In  short,  the  effect  of  movements  of  the  body  in  cases 
where  the  uterus  is  distorted  is  almost  invariably  to  pro- 
duce pain  or  inconvenience  more  or  less  marked.  This  is 
a  striking  fact,  and  has  the  greatest  significance  in  estimat- 
ing the  importance  of  uterine  flexions.  Why  is  it,  we  may 
ask,  that  this  movement,  these  exertions,  produce  pain  in 
cases  of  uterine  flexion  ?  Chassaignac  believed  it  to  be  on 
account  of  the  jars  or  ballottcments  the  uterus  receives.  No 
doubt  this  is  to  some  extent  true.  The  flexed  uterus  is 
shaken,  and  the  concussion  is  doubtless  in  part  the  cause  of 
the  painful  sensation.  But  there  is  another  and  a  far  more 
important  effect  to  which  I  would  direct  attention — viz.,  the 
temporary  exaggeration  produced  by  the  exertion  or  mo- 
tion of  the  body.  It  is  quite  certain  that  this  exaggeration 
and  increase  of  the  flexion  do  so  occur.  I  have  noted  it  in 
numberless  cases;  and  it  is,  I  feel  convinced,  the  main  cause 
of  the  pain.  If  corroborative  evidence  were  required,  it 
would  be  easily  afforded  by  carefully  investigating  any 
marked  case  of  this  kind  presenting  itself,  and  inquiring 
into  the  effects  of  this,  that,  or  the  other  motion  in  giving 
rise  to  pain;  the  very  closest  connection  will  then  be  shown 
to  exist  between  the  cause  and  effect  in  question.  Given 
a  certain  kind  of  uterine  flexion — determine  what  motion 
or  exertion  of  the  body  would  be  likely  to  exaggerate  that 
flexion:  let  the  patient  make  that  particular  exertion,  and  it 
will  be  found  to  give  rise  to  pain.  Thus,  in  a  case  of  severe 
retroflexion,  such  as  that  represented  in  Fig.  39,  it  is  obvi- 
ous that  motion  in  the  vertical  position,  walking,  for  in- 
stance, will  have  a  tendency  to  exaggerate  the  existing  flex- 
ion by  favoring  the  further  descent  backward  of  the  fundus 
uteri,  but  if  the  patient  be  in  the  prone  position,  as  shown 
in  Fig.  40,  it  is  evident  that  in  the  latter  position  (Fig.  40) 
the  exaggeration  of  the  flexion  is  not  liable  to  occur.  This 
prone  position  is  ahva^'s  found  to  be  the  most  comfortable 
one  in  cases  of  retroflexion.      In  fact,  investigation  into  the 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.   20/ 

effects  of  certain  exertions  will  often  lead  to  the  diagnosis 
of  the  nature  and  variety  of  the  flexion,  and  actual  exam- 
ination is  afterward  found  to  confirm  the  diagnosis  so  made. 
Further  evidence  in  the  same  direction  is  afforded  by 
placing  the  uterus,  or  even  by  placing  the  body,  in  such  a 
position  that  exaggeration  of  the  flexion  cannot  be  produced 
by  motion.     It  is  observed  under  such  circumstances  that 

Fig.  39.* 


pain  is  no  longer  produced,  or  it  is  at  ail  events  verv  much 
diminished.  By  mechanically  preventing  further  increase 
of  the  flexion  it  will  be  found  that  motion  has  no  longer 
the  same  effect  in  regard  to  this  particular  symptom. 

A  further  question  remains  to  be  answered,  and  it  is  the 
most  interesting  of  all — namely,  why  is  it  that  flexion  of 
the  uterus  gives  rise  to  pain,  and  why  does  the  temporary 

*  Fig.  39  represents  severe  retroflexion  of  the  uterus,  the  patient  being 
in  the  vertical  position. 


2o8 


DISEASES   OK  WOMEN. 


exaggeration  of  the  flexion  increase  the  pain  ?  We  have 
carried  the  analysis  to  this  point,  tliat  the  pain  and  the 
flexion  are  associated,  and  the  increase  in  the  degree  of  the 
flexion  is  found  to  be  answerable  for  increase  in  the  amount 
of  pain  present.  The  clinical  proofs  of  the  accuracy  of 
these  statements  which  have  presented  themselves  to  me  in 
the  course  of  several   years"  observation  are  to  my   mind 

Fig    40  "* 


conclusive  on  these  puinis.  The  answer  to  the  further  ques- 
tion, why  a  temporary  increase  of  the  flexion  gives  pain,  in- 
volves the  consideration  of  important  pathological  ques- 
tions. Hitherto  we  have  dealt  with  the  purely  physical 
elements  concerned — the  shape,  outline,  variations  of  shape, 

*  Fig.  40  represents  severe  retroflexion  of  the  uterus,  the  patient  being 
in  the  prone  position. 


DISPLACEMENTS,    DISTORTIONS   OF   THE   UTERUS.    209 

etc.,  of  the  uteius.  We  now  pass  into  a  different  territory, 
and  enter  on  a  ground  which  has  been  a  field  of  contention 
and  disagreement  to  an  extreme  degree.  Pain  necessarilv 
implies  an  affection  of  nerves.  When  any  part  of  the  body 
is  the  subject  of  physical  alteration  or  change,  pain  is  al- 
most universally  present,  this  pain  being  directly  trace- 
able, as  a  rule,  to  the  physical  impression  of  this  alteration 
or  to  some  change  implicating  the  sensitive  terminal  fibres 
of  the  nerves  themselves.  One  common  cause  of  such 
effect  is  well  known  to  be  inflammation.  Inflammation  of 
an  organ  shut  in  by  a  tightly  constricting  membrane,  such 
as  the  testis,  for  instance,  how  acute  is  the  pain!  this  acute 
character  being  probably  due  to  the  great  pressure  on  the 
nerves  necessarily  occurring  under  these  circumstances. 
The  more  closely  tlie  phenomena  of  pain  are  examined, 
the  more  evident  does  it  seem  that  pressure  upon,  or  undue 
tension  of,  the  ultimate  sensory  portions  of  the  nerves  is 
the  cause  of  the  pain.  Pains  referable  to  the  uterus  have 
had  various  explanations.  By  many  they  are  regarded  as 
fanciful  or  imjiginary.  or  due  to  inflammation  or  to  neural- 
gia. But  no  intelligible  and  consistent  explanation  has,  so 
far  as  I  am  aware,  been  given  of  the  tnodus  operandi  of  the 
production  of  these  pains. 

The  explanation  which  I  have  to  give  is  sufficiently  sim- 
ple; my  only  fear  is  that  its  very  simplicity  may  prove  a 
bar  to  its  being  accepted  to  the  extent  which  is  desirable  in 
the  interests  of  truth  and  progress.  It  is  that  the  pain  is 
produced  by  the  actual  compression  of  the  nerves  at  the 
seat  of  the  flexion.  My  observations  have  led  me  to  con- 
clude that  the  compression  and  condensation  of  the  tissues 
of  the  uterus  which  occur  at  the  seat  of  the  bend  is  the  im- 
mediate cause  of  this  pain.  This  pain  is  increased  for  the 
moment,  and  it  is  very  frequently  actually  brought  on,  by 
any  circumstance  tending  to  condense  and  compress  these 
tissues  still  more.  Such  an  event  happens  when,  from  any 
physical  cause  whatever,  the  uterus  becomes  more  flexed. 
It  is  my  belief  that  the  circumstance  of  the  additional  com- 
pression is  responsible  for  the  pain.  But  it  is  to  me  quite 
conceivable  that  this  may  not  be  the  whole  of  the  explana- 
tion. Another  theory  might  be  well  set  up,  and  perliaps 
ably  sustained.  It  might  be  urged  that  the  congestion, 
engorgement,  fulness,  or  whatever  you  please  to  term  it,  of 
the  body  of  the  uterus  and  of  the  cervix  and  os  uteri,  which 
are  so  frequently  present  in  cases  of  flexion,  are  concerned 


2IO  DISEASES   OF   WOMEN. 

in  the  production  of  the  pain.  As  I  shall  hereafter  show, 
congestion  of  the  two  extremities  of  the  uterus,  the  fundus 
and  OS,  are  almost  constant  accompaniments  of  decided 
uterine  flexions,  and  it  is  susceptible  of  absolute  proof  that 
the  more  acute  is  the  flexion  the  greater  is  the  congestion 
and  engorgement.  Plainly,  therefore,  it  may  be  said,  Why 
do  you  not  attribute  the  increased  pain  during  locomotion 
in  cases  of  flexion  to  temporary  increase  of  the  congestion? 
For,  it  might  be  added,  this  increase  of  congestion  would 
produce  further  compression  of  the  nerves  of  the  body  of 
the  uterus.  In  fact,  according  to  this  mode  of  reasoning, 
it  might  be  made  to  appear  probable  that  the  pain  in 
question  is  due  to  increased  tension  of  the  nerves  of  the 
body  of  the  uterus  set  up  by  temporary  increase  of  the  con- 
gestion of  the  part  in  question.  Admitting,  however,  that 
much  may  be  said  in  favor  of  this  latter  view,  observation 
has  induced  the  adoption  on  my  part  of  the  former  idea  as 
to  the  mechanism  of  the  production  of  the  pain.  The  con- 
comitant congestion  of  the  other  parts  of  the  uterus  doubt- 
less contributes  to  the  pain,  but  it  would  seem  to  me  prob- 
able that  it  does  so  mainly  because  it  has  a  tendency  to 
increase  the  compression  of  the  tissues  at  the  seat  of  the 
flexion.  The  presence  of  nervous  filaments  throughout  the 
uterine  tissues  is  generally  admitted,  though  there  are  dif- 
ferences of  opinion  as  to  their  actual  size.  At  its  central 
portion  around  the  internal  os  uteri  there  are  nervous  fila- 
ments forming  part  of  those  tissues.  When  compression  of 
the  uterine  tissues  at  this  situation  occurs,  these  filaments 
participate  in  that  compression:  hence  the  sensation  of  pain. 
There  are  still  other  views  as  to  the  etiology  of  the  pain 
in  question  to  be  considered.  It  seems  probable  that  some 
part  of  the  discomfort  felt  by  the  subjects  of  uterine  flexion 
during  locomotion  is  due  to  the  stretching  and  tension  of 
the  ligaments  or  attachments  of  the  uterus.  Thus  the 
feelings  described  as  "sinking"  and  "bearing  down," 
wliich  are  often  complained  of,  seem  due  to  this  tension  of 
the  uterine  attachments.  The  round  ligament,  the  broad 
ligaments,  and  the  utero-ovarian  ligament  are  the  ligaments 
principally  affected — some  more,  some  less.  The  so-called 
ovarian  pain,  which  has  for  a  long  time  been  considered 
evidence  of  ovarian  inflammation,  is  generally  traceable, 
according  to  my  experience,  to  uterine  flexion,  and  to  be 
produced  by  the  traction  of  the  connection  between  the 
ovary  and  the   uterus  caused  by  the  flexion.     In  cases  of 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.   211 

retroflexion  a  severe  pain,  situated  near  the  groin  on  one  or 
other  side,  is  in  rare  cases  observed,  and  has  appeared  to 
ine  to  arise  from  tension  and  stretching  of  the  round  liga- 
ment. In  this  place  also  it  is  proper  to  direct  attention  to 
the  fact  that  when  the  ovary  is  actually  displaced  down- 
ward, as  is  sometimes  the  case  in  flexion  of  the  uterus  back- 
v.'ard,  the  pain  produced  by  locomotion  is  very  acute  and 
severe.  This  displacement  of  the  ovarj'  is,  however,  by  no 
means  a  common  complication  of  uterine  flexion. 

3.  Uiidite  Tciukrness  of  the  Uterus  to  the  Touch. — In  the  next 
place,  we  have  to  consider  tenderness,  or  undue  sensitive- 
ness, of  the  uterus  to  the  touch,  and  the  relation  of  this 
symptom  to  flexions  of  the  uterus.  In  a  state  of  health  the 
uterus  is  not  highly  sensitive  to  the  touch.  And  even  the 
passage  of  the  uterine  sound,  if  carefully  performed,  hardly 
gives  rise  to  a  painful  sensation  until  it  touches  the  fundus 
uteri,  when  there  is  generally  evidence  of  slight  pain.  But, 
under  certain  conditions,  we  find  the  uterus  extremely 
sensitive  and  painful,  so  much  so  that  the  slightest  touch 
gives  rise  to  acute  pain.  I  need  hardly  say  that  those  cases 
where  the  entrance  of  the  vagina  is  acutely  sensitive  to  the 
touch — hyperaesthesia  of  the  vagina  as  they  are  termed — 
are  not  included  in  the  present  discussion.  Undue  tender- 
ness of  the  uterus  may  be  present  in  all  degrees;  the  os 
uteri  alone  may  be  affected,  or  the  posterior  or  anterior  as- 
pects of  the  uterus.  In  severe  cases  the  whole  uterus  ap- 
pears sensitive  to  the  touch. 

Respecting  the  connection  existing  between  tenderness 
of  the  uterus  and  alteration  of  its  shape,  I  claim  to  have  es- 
tablished a  most  important  generalization  and  conclusion, 
which  is  to  the  effect  that  tenderness  of  the  uterus  to 
the  touch  is  rarely  observed  except  in  cases  where  flexions 
are  present.  The  more  acute  the  flexion,  the  more  acute, 
as  a  rule,  is  the  tenderness.  Tenderness  is  not  invariably 
present  in  cases  of  acute  flexion,  and,  indeed,  when  cases 
have  become  quite  chronic,  there  may  be  little  or  no  ten- 
derness. My  proposition,  therefore,  is  not  that  cases  of 
flexion  of  the  uterus  are  always  attended  with  tenderness, 
but  that,  when  tenderness  is  present,  it  is  in  all  but  a  very 
few  cases  (I  have  not  myself  met  with  more  than  one  really 
exceptional  case)  associated  with  the  presence  of  uterine 
distortion.  Possibly  this  may  be  considered  a  bold  asser- 
tion, but  I  confidently  make  myself  answerable  for  its  sub- 
stantial accuracy. 


212 


DISEASES  OF  ^YOMEN. 


As  long  ago  as  the  year  x868,  I  published  in  the  Prac- 
titioner a  paper,  having  for  its  object  to  show  that  the 
"  irritable  uterus"  of  Dr.  Gooch  is  nothing  more  than 
chronic  severe  retroflexion  of  the  uterus.  Dr.  Gooch's 
description  of  these  cases  is  well  known:  "A  young  or 
middle-aged  woman,  somewhat  reduced  in  flesh  and 
health,  almost  living  on  her  sofa  for  months,  or  even 
years,  from  a  constant  pain  in  the  uterus,  which  renders 
her  unable  to  sit  up  and  take  exercise.  The  uterus,  on 
examination,  unchanged  in  structure,  but  exquisitely  ten- 

FiG.  41.* 


der;  even  in  the  recumbent  position  always  in  pain,  but 
subject  to  great  aggravations  more  or  less  frequently." 
Dr.  Fergusson,  who  edited  Gooch's  writings  some  few  vears 
since,  speaks  of  a  congested  condition  of  the  uterus' "al- 
tering its  shape  into  that  of  a  retort,"  as  having  existed 
in  some  instances,  though  he  does  not  appear  either  to 
have  connected  the  retort  shape  with  the  congestion,  or  to 
have  considered  it  as  in  any  way  concerned  in  the  pro- 
duction of  the  pain.  In  my  paper  I  proceeded  to  show 
that  this  retort  shape  of  the  uterus  was  a  necessary  part 
and  parcel  of  the  affection,  and  expressed  my  opinion  that 
these    so-called    cases  of  "  irritable  uterus"  were    actuallv 


*  Severe  rciroflexion  of  ilic  uterus. 


DISPLACEMENTS,   DISTORTIONS   OF  THE    UTERUS.   213 

cases  of  chronic  retroflexion.  Since  this  paper  was  writ- 
ten I  am  not  aware  that  any  refutation  of  this  view  has 
been  published;  and  the  only  further  observation  I  have 
to  make  on  the  subject  of  Gooch's  irritable  uterus  is,  that 
I  have  since  seen  many  cases  of  this  kind  in  which  the 
condition  of  the  uterus  amply  sustained  the  view  in  ques- 
tion. But  there  is  a  slight  qualification  to  make — viz., 
that  the  same  symptoms  may  be  observed  in  connection 
with  anteflexion  of  the  uterus  as  with  retroflexion.  The 
typical  and  most  severe  cases  are  those  of  retroflexion, 
but  in  severe  cases  of  anteflexion  the  symptoms  may  be 
very  much  the  same.  Further  inquiries  and  observations 
have  made  me  acquainted  with  the  close  connection  ex- 
isting between  distortion  of  shape  and  tenderness  of  the 
uterus,  of  which  Gooch's  cases  of  irritable  uterus  constitute 
well-marked  and  extreme  instances. 

A  very  acute  flexion  is  usually  attended  with  great  con- 
gestion. The  conjunction  of  the  two  gives  rise  to  the  great- 
est degree  of  tenderness.  And,  inasmuch  as  the  uterus  may 
become  more  bent  when  the  fundus  is  turned  backward 
than  when  turned  forward,  the  retroflexion  cases  are,  as  a 
rule,  the  most  severe,  and  accompanied  with  the  greatest 
tenderness.  In  cases  where  there  is  much  congestion  the 
tenderness  is  more  evident  when  the  body  of  the  uterus  than 
when  the  cervix  is  touched.  In  backward  flexions  the  fun- 
dus is  often  found  so  tender  that  the  merest  touch  gives 
acute  agony,  and  the  act  of  def^ecation  is  attended  with 
great  suffering.  In  acute  anteflexions  the  fundus  is  gener- 
ally less  easily  felt,  owing  to  the  intervening  bladder,  but 
the  presence  of  acute  sensitiveness  of  the  fundus  can  often 
be  substantiated  in  these  cases. 

It  is  worthy  of  mention  that  considerable  sensitiveness  to 
touch  is  sometimes  found  on  examination  in  cases  where 
other  symptoms  —  pain  on  locomotion,  etc., — have  been 
slight  in  degree;  and  under  these  circumstances  the  exam- 
ination reveals  the  grave  nature  of  the  case. 

The  sensitiveness  of  the  uterus  in  cases  of  flexion  may  be 
associated  with  slighter  degrees  of  congestion.  It  may  be 
l)resent  also  in  cases  where  the  congestive  stage  has  passed 
away,  leaving  the  uterine  tissues  hard  and  hypertrophied. 
In  these  latter  cases  the  tenderness  is  less  universally  spread 
over  the  uterus. 

Extreme  sensitiveness  is  met  with  in  many  quite  chronic 
cases  of  flexion  at  the  internal  os  uteri  or  its  neighborhood. 


214  DISEASES    OF   WOMEN. 

The  existence  of  this  sensitiveness  is,  of  course,  only  ascer- 
tained by  the  use  of  the  sound.  This,  however,  seems  the 
place  to  mention  it.  Under  these  circumstances  there  ex- 
ists a  severe  chronic  neuralgia  at  the  internal  os.  The 
subjects  of  this  affection  have  well-marked  pain  on  locomo- 
tion, always  situated  in  some  one  spot.  Thus,  in  two  very 
chronic  anteflexion  cases  where  this  severe  internal  sensi- 
tiveness existed,  walking  always  occasioned  so  severe  a  pain 
in  the  inguinal  region  that  it  had  to  be  given  up,  and  the 
sofa  had  become  always  necessary. 

Dystnenorrhoea. — Uterine  flexions  are  not  the  sole  cause  of 
dysmenorrhcea.  Again,  flexions  of  the  uterus  are  not  al- 
ways attended  with  dysmenorrhcea.  One  of  the  most  fre- 
quent effects  of  flexion  of  the  uterus  is,  however,  to  produce 
impediment  to  the  escape  of  the  menstrual  fluid — an  effect 
generally  due  to  compression  of  the  uterine  canal  at  its 
narrowest  part,  viz.,  the  internal  os  uteri.  The  compression 
has  the  same  effect  as  if  there  were  an  actual  stricture  of 
the  part.  Flexions  of  the  uterus  are  in  practice  found  to 
be  the  principal  cause  of  the  severe  pain  felt  during  men- 
struation as  well  as  of  the  extreme  difficulty  with  which  the 
exit  of  the  menstrual  products  may  be  attended.  Dysmen- 
orrhcea is  often  the  first  symptom  observed  in  cases  of 
flexion,  and  although  slight  dysmenorrhcea  is  no  proof  of 
the  existence  of  severe  flexion  of  the  uterus,  it  may  be  stated 
that  when  the  dysmenorrhcea  is  chronic  it  may  be  assumed 
that  there  is  an  impediment  to  the  escape  of  the  menstrual 
fluid,  which  impediment  is  in  all  probability  due  to  the  exist- 
ence of  uterine  flexion.  In  the  chapter  on  Dysmenorrhcea 
further  remarks  on  this  subject  will  be  found. 

Leucorrhcca. — Flexions  are  a  very  common  cause  of  leu- 
corrhoea,  and  there  are  few  cases  of  flexion  in  which  leu- 
corrhoea,  to  a  greater  or  less  degree,  does  not  occur.  In 
the  chapter  on  Leucorrhoea  further  remarks  on  the  subject 
will  be  found.  Here,  however,  it  is  necessary  to  point  out 
the  particular  relation  which  subsists  between  flexions  of 
the  uterus  and  "leucorrhoea  from  retention,"  as  it  may  be 
appropriately  termed.  One  of  the  effects  of  flexion  not 
rarely  observed  is  retention  of  the  secretions  of  the  uterine 
cavity  within  it,  owing  to  the  retort  shape  of  the  uterus, 
and  the  (virtual)  closure  of  the  internal  os  uteri. 

There  are  a  certain  number  of  cases  occurring  not  very 
rarely  in  which,  during  the  inter-catamenial  intervals,  there 
are  observed  from  time  to  time — perhaps  once   in  two  or 


DISPLACEMENTS,    DISTORTIONS   OF   THE   UTERUS.   21$ 

three  days,  and  generally  particularly  during  the  week  or 
ten  days  immediately  following  catamenial  cessation — dis- 
charges of  a  puriform  character,  coming  on  suddenly,  last- 
ing for  a  brief  period  only,  and   then   ceasing.     There  is  a 

Fig.  42.* 


puriform  leucorrhoea  occurring  in  gushes.  This  occurrence 
is  due  to  the  existence  of  chronic  flexion  and  arises  from 
imperfect  emptying  of  the  uterus.  At  the  close  of  the  or- 
dinary menstrual  period  something  is  still  left  in  the  uter- 
us.    This  unevacuated   fluid   undergoes   changes  resulting 

*Fig.  42  shows  the  third  stage  of  anteflexion  with  distension  of  cavity 
and  thickness  of  uterine  walls,  such  as  may  be  found  in  cases  of  chronic 
nienorrhagia  and  leucorrhoea  occuriing  in  gushes. 


2l6  DISEASES   OF  WOMEN. 

in  its  conversion  into  puriform  fluid.  -  The  uterus  becomes 
distended  with  this  accumulation.  It  is  increased  by  the 
addition  of  further  fluid  of  a  watery  character,  poured  out 
by  the  lining  of  the  uterus,  and  when  distension  reaches  a 
certain  point,  it  is  expelled.  That  is  to  sa}',  it  is  partly  ex- 
pelled, but  after  a  time  further  distension  occurs,  followed 
by  fresh  expulsion.  I  have  observed  many  cases  of  this 
kind — in  fact,  the  occurrence  of  puriform  leucorrhaea  com- 
ing away  in  gushes  is  by  itself  almost  diagnostic  of  the  ex- 
istence of  a  chronic  flexion  of  the  uterus,  and,  during  an 
experience  of  some  years,  this  sign  has  proved  of  great 
value.  Patients  suffering  from  this  affection  sometimes 
describe  what  they  term  "  little  abscesses"  bursting  from 
time  to  time.  In  certain  rare  cases  the  retained  uterine  con- 
tents are  actually  offensive  to  the  smell,  the  fluid  having 
become  putrescent  before  it  is  discharged.  The  uterus  be- 
comes irritated,  and  the  lining  membrane  secretes  more  fluid 
than  usual;  there  is,  in  short,  w^hat  is  termed  endometritis. 

Mefiorrhagia. — The  menstrual  periodic  discharge  is  fre- 
quently increased  inquantit}'  in  cases  of  flexion,  though  by 
no  means  constantly  so — for  the  quite  opposite  effect  may 
be  noted.  Nevertheless,  taking  all  cases  of  menorrhagia, 
one  with  another,  the  commonest  cause  is  found  to  be 
either  uterine  flexion,  or  some  of  the  secondary  effects  re- 
sulting from  uterine  flexion. 

Menorrhagia  occurs  often  in  consequence  of  the  impedi- 
ment to  escape  of  blood;  the  blood  accumulates  in  the 
uterus,  distends  it,  and  is  from  time  to  time  expelled  in 
gushes.  The  process  observed  is  sometimes  like  that 
of  labor  on  a  small  scale,  the  patient  experiencing  severe 
recurrent  pains;  and  after  a  time  these  pains  result  in 
expulsion  of  blood  in  considerable  quantity:  here  we  have 
dysmenorrhcea  and  menorrhagia  combined.  After  a  time 
the  uterus  becomes  hypertrophied,  its  cavity  permanently 
dilated,  and  the  area  of  its  internal  surface  proportionately 
extended.  Then  the  patient  becomes  subject  to  perma- 
nent menorrhagia,  and  the  quantity  lost  at  each  period  may 
be  exceedingly  great.  Examination  reveals  probably  the 
existence  of  long-standing  flexion,  with  considerable  hyper- 
trophy of  the  whole  uterus;  or  the  whole  organ  may  be  found 
in  a  loose,  soft,  congested,  sponge-like  condition,  the  blood 
poor  and  watery  in  character  from  long-continued  losses, 
and  the  large  retort-shaped  uterus  pouring  out  much  blood 
for  many  days  together. 


DISPLACEMENTS,    DISTORTIONS   OF   THE    UTERUS.    217 

Tlie  presence  of  clots  in  cases  of  menorrhagia  is  some- 
times noticed.  Sometimes  such  clots  are  formed  in  the  va- 
gina, but  more  generally  they  originate  in  the  cavity  of  the 
uterus.  Retention  of  blood  is,  probably,  the  first  event  in 
such   cases;  the  blood    so  retained  becomes  clotted,    and 

Fig.  43.* 


lias  hnaily  lu  be  expelled.  The  passage  of  the  clot  through 
this  narrow  internal  os  uteri  necessarily  occasions  much 
pain.  The  dysmenorrhoea  is  most  severe  in  cases  where 
clots  have  to  be  got  rid  of,  and  the  pain  is  sometimes  of  a 
most  agonizing  character.     In  some  cases  the  clot  never  is 


*  Fig.  43  represents  severe  antefle.xion  with  enlarjjed  uterine  cavity, 
as  in  Fig.  42,  but  the  position  of  the  pelvis  is  here  altered,  as  if  the  pa- 
tient were  recumbent  on  the  ba'-k.  The  tendency  of  this  position  is  ob- 
viously to  throw  the  fundus  upward  and  backward. 


21 8  DISEASES  OF  WOMEN. 

expelled  as  such,  but  becomes  broken  up.  No  doubt  some 
of  the  cases  where  a  sanious  leucorrhoea  is  observed  for  a 
few  days  after  the  regular  period  is  over  are  cases  of  this 
kind;  the  clots  retained  break  down,  and  the  debris  are 
gradually,  but  slowly,  expelled. 

It  must  be  further  remarked  that  the  difficulty  experi- 
enced by  the  uterus  in  relieving  itself  of  the  retained  pro- 
ducts in  cases  such  as  above  described  is  materially  in- 
creased by  the  dependent  position  of  the  pouch  containing 
the  fluid.  When  the  patient  is  upright,  and  the  body  of  the 
uterus  strongly  bent  forward  or  backward,  the  action  of 
gravity  is  opposed  to  the  evacuation  of  the  uterine  contents 
(see  Figs.  23  and  18).  Thus,  in  the  retort-shaped  uterus, 
the  enlarged  pouch  hangs  downward,  forward,  or  back- 
ward, as  the  case  may  be,  and  the  fluid  must  move  really 
upward,  in  order  to  pass  through  the  internal  os  viteri, 
where  the  obstruction  which  exists  further  adds  to  the  dif- 
ficulty. The  double  difficulty  of  moving  upward  in  a  direc- 
tion opposed  to  the  action  of  gravity  and  moving  round  a 
corner  presents  itself  under  such  circumstances.  Clinical 
observation  offers  convincing  proofs  of  the  operation  of 
these  natural  laws.  Thus  it  may  be  found  that  in  a  case  of 
anteflexion,  with  purulent  retention,  the  discharge  is  free 
and  continuous  so  long  as  the  patient  remains  in  bed,  but 
on  rising  in  the  morning  it  suddenly  ceases,  appearing  only 
in  gushes  at  intervals  during  the  day,  and  on  lying  down 
again  at  night  a  further  comparatively  free  and  continuous 
escape  of  fluid  occurs. 

Affienorr/uva. — The  effect  of  uterine  flexion  in  arresting 
the  discharge  for  a  time  has  been  mentioned,  but  in  connec- 
tion with  menstrual  retention  only.  In  a  certain  number  of 
cases,  however,  the  discharge  becomes  gradually  less  and 
less,  the  periods  become  habitually  "scanty,"  and  in  a  few 
the  discharge  ceases.  Actual  suppression  of  menstruation 
for  some  months,  or  its  premature  termination  at  a  com- 
paratively earl)'  age,  is  now  and  then  observed,  in  cases  of 
acute  flexion.  Probabh'  the  compression  of  the  organ 
which  is  the  effect  of  the  flexion  has  much  to  do  with  it. 
The  uterus  having  its  circulation  interfered  with  is  no 
longer  capable  of  carrj'ing  on  its  function  properly. 

The  whole  process  is  occasionally  witnessed.  In  a  known 
case  of  flexion,  menstruation  is  for  a  time  scanty.  Each 
month  it  is  less  in  quantity.  By  and  by  a  month  is  passed 
over  without  discharge.     After  a  time  the  interval  is  longer. 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.   219 

And,  concurrently  with  these  effects,  other  symptoms  are 
noticed,  which  _e;ive  evidence  that  the  flexion  lias  become 
aggravated.  The  flexion  is  now  dealt  with  and  treated, 
and  the  amenorrhoea  ceases.  Cases  of  this  kind  are  inier- 
fsting  and  convey  important  clinical  lessons  (see  chapter  on 
Amenorrhcea). 

Steiility. — Any  circumstance  producing  imperviousness  of 
the  external  or  internal  os  uteri  must  necessarily  produce 
sterility,  and  flexions  are  responsible  for  this  result  in  very 
many  cases,  the  narrowed  condition  of  the  internal  os  ob- 
structing the  passage  of  fluid  upward.  But  in  very  many 
cases  the  mere  obstruction  is  not  the  sole  cause  of  the  ster- 
ility. Another  circumstance  is  to  be  taken  into  considera- 
tion— viz.,  the  altered  condition  of  ihelining  of  the  body  of 
the  uterus,  which,  as  previously  pointed  out,  is  liable  to  be 
produced  by  retention  of  secretions  within  the  uterine  cav- 
ity. These  retained  secretions  have  doubtless  a  powerful 
influence  in  deranging  the  physiological  process  and  dam- 
aging the  products  of  conception.  Further,  an  irritated  al- 
tered mucous  membrane,  such  as  must  be  present  in  such 
cases,  cannot  ot'fer  a  proper  surface  for  the  attachment  and 
growth  of  the  ovum,  even  supposing  it  has  been  impreg- 
nated and  has  descended  into  the  uterine  cavitv. 

Abortions. — Hy  far  the  most  common  cause  (jf  abortions 
is  the  existence  of  flexion  of  the  uterus.  The  almost  in- 
cessantly observed  conjunction  of  the  two  elements — exist- 
ence of  a  known  flexion  of  the  uterus  and  liability  to  abor- 
tion in  the  same  individual — has  led  me  to  this  conclusion. 
There  are  undoubtedly  other  causes  of  abortion — syphilis, 
lead  poison,  accidents,  falls,  blows,  mental  emotions,  etc. 
But,  after  all,  cases  referable  to  these  heads  coUectivelv 
form  a  very  small  percentage  of  the  number  of  cases  of 
abortion  actually  observed. 

The  connection  between  retroflexion  of  the  uterus  anrl 
liability  to  abortion  is  tolerably  well  recognized.  But  it  is 
not  so  well  known  that  anteflexion  is  a  rather  common 
cause  of  abortion. 

The  proof  of  the  truth  of  the  statement  that  abortion  is 
often  due  to  uterine  flexion  is  necessarily  to  be  obtained 
only  from  careful  clinical  observations.  Such  observations 
only  require  to  be  made  in  order  that  the  proofs  may  be 
obtained  necessary  to  convince  others  as  they  have  con- 
vinced me.  Clinical  histories,  such  as  the  fr)llo\ving.  consti- 
tute important  evidence.     In  a  case  of  known  anteflexion, 


220  DISEASES   OF  WOMEN. 

pregnancy  occurs,  and  is  shortly  followed  by  an  abortion. 
In  another  case,  a  flexion  is  undergoing  treatment;  becomes 
relieved  up  to  a  certain  point;  pregnancy  occurs,  and  abor- 
tion happens.  In  another  case  also  where  flexion  is  known 
to  exist,  pregnancy  happens,  and  the  patient  goes  to  full 
term;  recovers  from  her  confinement;  becomes  again  preg- 
nant, and  is  threatened  with  an  abortion.  On  examination 
it  is  found  that  the  old  evil  has  recurred;  the  uterus  is  in  a 
state  of  flexion.  Take  another  class  of  cases.  In  a  certain 
case  abortion  happens,  the  ovum  partly  escapes;  the  thick- 
ened decidua  and  commencing  placenta  are  retained  in 
utero.  Examination  is  made,  and  the  uterus  is  found 
acutely  anteflexed  or  retroflexed.  A  succession  of  such 
cases  present  themselves,  the  circumstances  being  a  little 
varied.  What  other  opinion  can  be  arrived  at  than  that 
the  abortion  is  due  to  the  flexion  ?  I  assume,  of  course, 
that  the  operation  of  other  possible  causes  of  abortion  is 
duly  regarded,  and  the  particular  case  excluded  from  these 
categories.  Complete  the  proof  :  trace  the  further  history 
of  these  very  cases,  and  suppose  it  to  be  found  that  the 
phenomena  described  have  a  great  tendency  to  recur.  Let 
this  kind  of  observation  be  made  over  and  over  again,  and 
conviction  naturally  follows. 

The  following  table  contains  a  statistical  account  of  cases 
in  hospital  and  private  practice,  with  interesting  particulars 
in  reference  to  the  question  as  to  the  influence  of  flexion  of 
the  uterus  in  producing  sterility  and  in  inducing  a  liability 
to  abortion.  Some  of  the  facts  were  observed  in  hospital 
practice  two  3'ears  ago.  A  second  series  of  facts  are  the 
results  observed  in  private  practice.  And  the  two  series  of 
facts  are  so  arranged  that  they  can  be  compared.  The 
general  conclusion  to  be  drawn  is  that,  taking  100  patients 
affected  with  flexion  of  the  uterus,  it  may  be  expected  that 
in  about  one  half  of  them  sterility  or  abortions  will  occur. 
There  is  a  remarkable  coincidence  in  regard  to  the  two 
classes  of  cases,  hospital  and  private,  there  being  sterility 
or  only  abortions  in  34  per  cent  in  both  series.  So  also  in 
regard  to  fecundity,  for,  in  the  hospital  series,  65  per  cent 
bore  children  (including  11  per  cent  who  also  had  abor- 
tions), and  in  the  private  practice  series  67  per  cent  had 
had  children  (including  17  who  had  also  had  abortions). 

Of  those  absolutely  sterile — that  is,  who  had  never  had  a 
pregnancy  at  all — there  were  24  per  cent  of  the  hospital 
cases,  and  28  per  cent  in  the  private  cases. 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.   221 

Abortions  occur  very  frequently,  as  evidenced  in  the 
statistics  below.  There  w^ere  some  few  cases  (lo  per  cent 
in  the  hospital  series  and  5  per  cent  in  the  private  series) 
who  had  never  had  a  child,  but  had  had  abortions,  and  in 
addition  to  these  there  were  cases  in  which,  although  the 
patient  had  had  children,  there  had  been  noticed  abortions 
also — II  per  cent  in  the  hospital  series,  and  17  per  cent  in 
the  private  series.     The  total  percentage  of  cases  of  flexion 

Frequency  of  Sterility  and  Abortions  in  Cases  of  Flexions. 


Sterile  or 
only  abor- 
tions. 

Absolute- 
ly sterile : 
no  preg- 
nancy. 

Abor- 
tions 
only. 

Chil- 
dren & 
abor- 
tions. 

No 
abortion. 

Facts  as  to 
number  of 
children. 

Hosf>ital  Practice. 

Cases  of  uterine  flexion, 

1865-1869: 

I  135  anteflexion  1 

81 

57 

3 

27 

127 

"  1  100  retroflexion  1 

(34-4  p.  c.) 

(241P.C.) 

(10  p.  c.) 

("•4 
p.c.) 

(54  P-  c.) 

Private  Practice. 

Cases  of  uterine  flexion, 

1873-1879: 

668  cases. 

(499  married,  169  single) 

["360  anteflexion 

129  ■] 

107 1 

22I 

67I 

'^*1       0 
V47"8 

51  patients 

l34'2 

128-4 

1     5 

I  »7-8 

had  only 

499] 

fp.c. 

fp.c. 

P.O. 

p.c. 

p.c. 

I  child. 

1,139  retroflexion 

42  J 

35  J 

7J 

22  J 

75  J 

21  had  only 
I  child. 

in  which  abortion  was  noted  was,  for  hospital  cases  21  per 
cent,  for  private  cases  22  per  cent — figures  which  are  almost 
identical. 

The  above  figures  have  been  extracted  with  great  care 
from  records  of  cases  in  my  possession. 

It  may  be  well  in  the  next  place  to  speak  of  what  may 
be  termed  "secondary"  sterility  in  connection  with  flexions 
of  the  uterus.  There  is  abundant  evidence  that  flexions 
arising  after  labor  give  rise  not  seldom  to  sterility.  The 
patient  has  had  one  or  two  children  but  has  become  after- 
ward sterile.  The  following  table  gives,  from  records  in 
my  possession,  statistics  in  regard  to  the  influence  of 
flexions  in  producing  sterility  in  women  who  have  had 
children  : 


122 


DISEASES   OF  WOMEN. 


Cases  of  Fertility  with  Subsequent  Sterility. 
(Private  Practice.) 


Number  of  cases. 

Average  number  of 
years  elapsed  since. 

Variation  in  number 
of  yrs.  expired  since. 

One    child    only) 

(over  I  year      V 

expired  since) . . .  ) 

Two  children     1 
only  (over  i  year  >■ 
expired  since) . . .  ) 

I  Anteflexion     51 
(  Retroflexion   21 

(  Anteflexion     38 
(  Retroflexion    12 

Anteflexion   6'4  years. 
Retroflexion  8     years. 

Anteflexion   4' 4  years. 
Retroflexion  5 '  i  years. 

Anteflexion  i  to  22 

years. 
Retroflexion  i  to  24 

years. 

Anteflexion  i  to  16 

years. 
Retroflexion  i  to  14 

years. 

Disturbance  of  Functions  of  the  Bladder. — These  constitute 
a  class  of  symptoms  rather  common  in  cases  of  uterine 
flexion.  Great  frequency  of  micturition  is  often  observed 
in  anteflexion  cases.  This  symptom  is  sometimes  very  dis- 
tressing, there  being  a  perpetual  necessity  for  evacuating 
the  bladder,  as  often,  in  one  case,  as  every  five  or  ten  min- 
utes. Retention  of  urine  sometimes  occurs  as  a  consequence 
of  flexion — more  often  from  retroflexion.  Incontinence  of 
urine  is  occasionally  observed  as  a  result  of  retroflexion. 
Extreme  pain  in  the  bladder  after  evacuation  of  its  contents 
is  sometimes  noticed  in  cases  of  anteflexion,  apparently  due 
to  pressure  of  one  wall  of  the  empty  bladder  on  the  other. 

Taken  as  a  whole,  the  bladder  symptoms  are  not  always 
observed  in  cases  of  flexion,  but  they  sometimes  constitute 
the  chief  or  most  distressing  of  the  symptoms  of  which  the 
patient  complains. 

Disturbance  of  Functions  of  Rectum. — In  cases  of  uterine 
flexion  the  function  of  defaecation  is  often  interfered  with 
in  various  ways,  the  patient  finding  often  a  difficulty  in 
evacuating  the  contents  of  the  rectum,  in  consequence  of 
the  pressure  of  the  uterus  upon  it.  The  pressure  of  the 
uterus  acts  in  a  kind  of  valvular  manner,  and,  the  more  the 
patient  strains,  the  more  complete  is  the  closure.  In  other 
cases,  defaecation  is  attended  with  considerable  pain.  The 
most  aggraviited  cases,  and  they  are  not  very  commonly 
met  with,  are  those  in  which  there  is  retroflexion,  accom- 
panied by  rectocele.  The  perineum  is  partly  destroyed,  and 
the  rectum  protrudes  a  little  through  the  vaginal  aperture. 
The  uterus  is  retroflexed,  and  presses  down  the  rectum,  and 
it  thus  obstructs  the  canal;  a  state  of  things  may  then  arise 
which  produces  intolerable  anguish  to  the   patient.     The 


DISPLACEMENTS,   DISTORTIONS  OF  THE    UTERUS.   223 

rectum  may  become  ulcerated.  At  the  part  where  the 
rectum  projects  into  the  vagina  there  is  a  bend,  and  in  this 
position  ulcers  are  liable  to  form.  This  is  an  extreme  case, 
but  the  right  explanation  of  such  a  case  is  of  some  moment. 
Retroflexion  may  thus,  sometimes,  produce  what  appears  to 
be  a  serious  disease  of  the  rectum.  In  some  cases,  ante- 
version  leads  to  very  serious  interference  witli  defaecation. 
Clironic  and  troublesome  diarrhoea  is  sometimes  caused  by 
retroflexion  of  the  uterus. 

Pain  on  Intercourse — Dyspareunia. — This  is  a  symptom  and 
effect  of  the  presence  of  flexions  of  the  uterus  which 
deserves  attention.  There  are  of  course  other  conditions 
of  the  generative  organs  capable  of  giving  rise  to  the  symp- 
tom in  question,  but,  certainly,  flexions  of  the  organ  are 
most  common  causes. 

Reflex  Nervous  Symptoms. — The  symptoms  included  under 
this  heading  constitute  a  most  interesting  class.  The  exist- 
ence of  a  relationship  between  these  symptoms  and  the 
presence  of  uterine  flexion  is  only  now  beginning  to  be 
known  and  admitted  by  uterine  pathologists.  "  Nausea 
and  vomiting,"  "hysteria,"  "convulsions,"  "mental  de- 
rangements," are  the  more  important  of  these  reflex  symp- 
toms. It  is  impossible  to  discuss  the  whole  question  in 
this  place;  the  reader  is  referred  to  the  separate  chapters 
which  will  be  found  devoted  to  these  subjects.  Here  it  is 
necessary,  however,  to  say  that  the  clinical  evidence  of  the 
very  close  connection  as  cause  and  effect  between  uterine 
flexion  and  these  reflex  nervous  symptoms  is  most  distinct 
and  clear.  There  cannot  be  a  question  that,  in  the  future, 
as  observations  are  increased  in  number  the  truth  of  this 
statement  will  come  to  be  universally  admitted. 

Reflex  nervous  sj^mptoms  are,  however,  by  no  means 
always  present  in  every  case  of  uterine  flexion. 


224  DISEASES  OF  WOMEN. 


CHAPTER  XVIII. 

Displacements  and  Distortions  of  the  Uterus  (Flex- 
ions)— 6.  General  Principles  of  Treatment. 

Principles  of  Treatment. — Indications  i. —  Restoration  of  General 
Strength.     2.   Restoration  of  Uterus  to  Proper  Shape  and  Position. 

Difficulties  Encountered. — Question  of  Necessity  for  Examination — 
Definition  of  General  and  Local  Treatment — Curability  of  Flexions — 
Various  Causes  of  Difficulty. 

General  Treatment. — Restoration  of  Nutritional  Power  and  Activity — 
Rest,  how  to  be  carried  out — Utilization  of  Influence  of  Gravity — At- 
tention to  Condition  of  Bowels. 

Local  Treatment. — Positional  or  Postural  Treatment — Prone  Kneel- 
ing Position — Horizontal  Position.  Use  of  the  Sound  repeatedly — 
Cases  adapted  for  it.  Use  of  Sound  combined  with  Dilatation  of  Canal 
by  means  of  a  Dilating  Sound.  Treatment  by  means  of  Stems:  Cases 
requiring  it — its  Value  and  Applicability.  Use  of  Tents.  Incision  of 
the  Uterine  Canal.  Vaginal  Pessaries — General  Method  of  Action — 
Cases  suitable  for.  Necessit}^  for  conjoint  Postural  Treatment  and 
use  of  Sound.  Other  Requirements  when  Vaginal  Pessaries  are  em- 
ployed. Material  of  Vaginal  Pessaries.  General  Summary.  Palli- 
ative Treatment.  Use  of  Hot-water  Injections.  Opiates.  Treatment 
of  the  accompanying  Congestion. 

Various  modifications  in  regard  to  detail  and  mechanical 
procedure  are  required  in  different  cases  of  uterine  flexion. 
Here,  however,  it  is  intended  to  describe  the  general  prin- 
ciples of  treatment  of  these  affections. 

The  principal  indications  are: 

1.  To  restore  or  improve  the  general  strength  and  vital- 
ity of  the  patient,  almost  always  in  a  state  of  deterioration 
more  or  less  pronounced. 

2.  To  restore  the  uterus  to  its  proper  shape  and  position. 
The  above  indications  are  formulated  in  conformity  with 

the  general  views  which  have  been  set  forth  in  previous 
pages  in  reference  to  the  nature  and  cause  of  flexions  of 
the  uterus.  It  will  be  found  in  practice  impossible  satis- 
factorily to  treat  cases  unless  both  of  the  indications  al- 
luded to  receive  due  attention. 

Whether  the  first  or  the  second  indication  is  the  more 
important  will  depend  on  the  nature  of  the  particular  case. 

In  cases  where  the  flexion  is  slight  in  degree  and  recent  in 
occurrence,  general  measures  may  prove  entirely  effectual, 
the  uterus  participating  in  the  general  improvement  pro- 
duced by  the  treatment  in  question. 


DISPLACEMENTS,    DISTORTIONS   OF   THE    UTERUS.    22$ 

When,  however,  the  flexion  is  severe  and  of  long  stand- 
ing, no  amount  of  attention  to  the  general  treatment  will 
prove  efficacious  in  curing  the  flexion,  local  treatment  be- 
ing necessary  before  real  improvement  can  be  expected. 

In  severe  and  long-standing  cases  local  treatment  alone 
is  insufficient.  General  treatment  must  be  associated  with 
it  or  disappointment  will  be  experienced. 

At  the  outset  the  question  arises  as  to  the  employment 
of  local  treatment  of  the  uterus  in  cases  of  unmarried 
women  affected  with  the  disorders  now  under  considera- 
tion. It  may  be  well  to  consider  how  best  to  obviate  these 
difficulties. 

The  first  difficulty  is  as  regards  the  diagnosis.  In  young 
unmarried  women  the  diagnosis  is  at  first  of  course  only  pre- 
sumptive. Persistence  of  particular  symptoms  for  many 
months  in  succession,  such  as  marked  deterioration  of 
healtli,  obstinate  nausea,  dysmenorrhoea,  continued  diffi- 
culty in  locomotion,  continued  suffering  of  some  kind  refer- 
able to  the  uterus;  under  these  circumstances  a  com|)lete 
diagnosis  of  the  case  should  be  made,  instead  of  waiting, 
as  is  sometimes  done,  two  or  three  years  before  any  reliable 
information  is  attempted  to  be  gained.  In  many  cases  a 
tolerably  exact  notion  of  the  case  can  be  obtained  by  an 
examination  per  rectum,  or  it  can  be  thus  ascertained  if  a 
further  and  more  exact  investigation  is  required.  The 
diagnosis  made  even  in  this  imperfect  way  is  of  service  in 
pointing  out  what  general  metliod  of  treatment  is  likely  to 
be  of  use  (decision,  for  instance,  between  anteflexion  and 
retroflexion),  or  whether  the  affection  is  so  severe  as  to 
make  a  vaginal  examination  imperative.  In  young  unmar- 
ried women  an  anaesthetic  is  frequently  advisable  in  cases 
where  it  is  decided  to  make  a  vaginal  examination.  It  is 
impossible  to  lay  down  a  strict  line  of  conduct  for  all  cases. 
On  the  one  hand,  it  is  improper  to  subject  young  women 
to  vaginal  examinations  unless  they  are  considered  neces- 
sary after  proper  consultation  on  the  subject.  On  the  other 
hand,  it  must  be  borne  in  mind  that  the  foundation  of  a 
life-long  condition  of  invalidism  and  general  inefficiency 
may  be  laid  by  two,  three,  or  four  years'  neglect  of  a  severe 
uterine  flexion,  and  consequently  that  delay  in  making  a 
necessary  examination  may  be  most  injurious  to  the  patient. 
In  cases  where  the  symptoms  have  existed  for  some  years 
tliere  should  be  no  scruple  in  insisting  on  the  necessity  for 
9.  proper  examination. 


226  DISEASES   OF   WOMEN. 

Some  explanatory  remarks  are  here  required  respecting 
what  is  meant  by  general  and  local  treatment.  It  has 
already  been  stated  that  general  treatment  has  often  a  local 
effect.  As  regards  local  treatment,  the  most  efficacious  is 
mechanical.  By  mechanical  treatment  is  not  meant,  how- 
ever, the  use  of  instruments  or  necessarily  of  instrumental 
procedures.  There  are  methods  which  are  in  their  mode 
of  action  strictly  mechanical — utilizing  the  force  of  gravity, 
rest, and  the  like — although  not  including  surgical  procedure 
in  the  ordinai'y  sense  of  the  word. 

Cii?-ability  of  Uterine  Flexions. — The  apparently  intractable 
character  of  certain  forms  of  the  affection  has  led  some 
authorities  to  conclude  that  flexions  are  incurable.  As  a 
general  statement  this  is  undoubtedly  a  mistake,  although 
in  some  cases  a  complete  cure  is  no  doubt  very  difficult  to 
obtain. 

a.  One  source  of  difficulty  is  weakness  of  the  uterus  from 
malnutrition.  So  long  as  the  tissues  of  the  organ  remain 
soft  and  give  way  to  pressure,  the  cure  of  the  flexion  is  a 
matter  of  impossibilit)^ 

b.  Another  is  the  atrophy  often  present  in  long-standing 
flexions  at  the  seat  of  the  bend,  which  has  this  effect,  that 
while  it  ma)^  be  easy  to  maintain  the  organ  artificially  in  its 
normal  shape,  the  moment  the  assistance  ceases  the  flexion 
recurs.     The  uterus  has  virtually  lost  its  stem. 

c.  Another  is  the  rigidity  of  the  uterus.  It  has  become 
set  in  a  certain  abnormal  shape,  and  though  it  may  be  un- 
bent by  means  of  the  sound,  the  flexion  recurs  directly  it  is 
withdrawn.  This  rigidity  may  be  accompanied  with  atrophy 
around  the  internal  os,  or  not. 

d.  Another  diff.culty  is  the  presence  of  adhesions  tying 
the  fundus  down  in  its  abnormal  position. 

e.  The  most  common  difficult}',  however,  is  the  absence 
of  an  accurate  diagnosis  of  the  physical  condition  of  the 
uterus  in  the  particular  case. 

The  use  of  the  sound  is  an  important  aid  in  determining 
the  curability  of  a  given  case  of  flexion.  At  all  events,  it  is 
possible  by  its  means  to  measure  the  rigidity  of  the  uterus. 
By  gently  unbending  the  uterus  by  the  sound,  and  then 
withdrawing  it  and  observing  how  quickly  it  returns  to  the 
flexed  state,  the  degree  of  rigidity  is  indicated.  In  a  long- 
standing severe  retroflexion  we  suppose,  for  instance,  that 
the  sound  raises  the  fundus  up  to  its  proper  position,  but 
immediately  it  is  withdrawn  the  fundus  is  felt  by  the  finger 


DISPLACEMENTS,   DISTORTIONS   OF   THE   UTERUS.   22/ 

to  resume  its  old  position.  This  indicates  considerable 
rigidity;  but  the  fact  that  the  uterus  can  be  raised  by  the 
sound  shows  that  a  cure  is  possible.  The  degree  of  resist- 
ance encountered  in  changing  the  form  of  the  uterus  by 
the  sound  is  in  some  degree  a  measure  of  the  difficulty  of 
the  cure. 

The  presence  of  atrophy  in  the  uterine  wall  is  indicated 
by  the  touch;  the  sound  having  been  previously  introduced, 
the  thickness  of  the  uterine  wall  at  the  flexion  can  be  esti- 
mated by  the  pressure  of  the  finger  opposite  this  situation. 

Some  general  statements  may  be  made  as  to  the  curabil- 
ity of  different  cases. 

The  cases  are  most  amenable  to  treatment  in  which  the 
affection  is  of  not  over  two  years'  standing,  and  the  uterus 
not  very  resistant  to  the  restitution  of  proper  shape  by  the 
aid  of  the  sound. 

Cases  are  tolerably  amenable  to  treatment  up  to  the  age 
of  thirty,  even  when  the  affection  has  lasted  some  years, 
provided  that  there  is  no  considerable  parietal  atrophy,  that 
the  reposition  by  the  sound  is  not  very  difficult,  and  that 
tliere  are  no  other  complications. 

After  the  age  of  thirty  the  cure  of  long-standing  flexions 
becomes  more  and  more  difficult,  and  cure  at  the  age  of 
forty,  for  instance,  of  a  severe  retroflexion  of  ten  years' 
standing  would  be  very  difficult. 

As  a  rule  it  may  be  stated  that  the  time  required  to  effect 
a  cure  is  indirect  proportion  to  the  duration  of  the  disease. 
Recent  cases  are  cured  most  readily.  Recent  cases,  too, 
are  cured  most  completely,  for  long-standing  flexions,  even 
when  cured,  have  a  great  tendency  to  recur.  Thus,  I  could 
give  particulars  of  cases  both  of  anteflexion  and  retroflexion 
cured  so  that  the  patients  conceived  and  had  children,  and 
the  flexion  recurred  intermediately  three  or  four  times — i.e., 
once  after  each  labor  was  over — requiring  treatment,  which 
was  again  and  again  successful.  It  is  probable  that  when 
proper  attention  is  paid  to  the  general  treatment,  the  cure 
of  uterine  flexions  will  become  more  complete.  My  own 
experience  gives  reason  for  this  conclusion. 

Lastly,  it  is  to  be  stated  that  particular  kinds  of  flexion 
are  more  difficult  to  cure  than  others,  as  will  be  more  par- 
ticularly described  later  on  (see  chapters  on  Anteflexion 
and  Retroflexion). 

Dr.  Paul  F.  Munde  *  says,  "  Permanent  relief,  cure,  can 

*  Amer.  Jour,  of  Obstet.,  Oct.,  i88i. 


228  DISEASES  OF  WOMEN. 

be  expected  and  will  be  obtained  only  when  the  displace- 
ment is  of  recent  origin,  especially  when  it  has  been 
produced  by  some  sudden  physical  shock,  or  when  the 
complete  tissue-metamorphosis  accompanying  puerperal 
involution  aids  in  restoring  to  the  uterine  supports  and  to 
the  uterus  itself  their  original  and  healthy  tone." 

Pessaries,  according  to  Dr.  Munde,  give  temporary  re- 
lief, but  cure  only  in  a  few  cases.  He  prefers  the  wearing 
of  astringent  vaginal,  tampons  introduced  daily,  for  some 
cases  of  ante-  and  retro-displacement,  and  considers  this 
method  the  only  efficient  and  safe  remedy  for  most  cases  of 
procidentia.  He  contends  that  this  treatment  is  preferable 
to  the  use  of  hard  or  soft  pessaries. 

Dr.  Munde's  views  as  to  the  difficulty  of  cure  are  to  a 
certain  extent  correct,  but  I  think  the  difficulty  is  over- 
stated. The  importance  of  seizing  the  time  of  puerperal 
involution  for  remedying  the  shape  of  the  uterus  is  cer- 
tainly great,  as  Dr.  Munde  points  out;  but,  unfortunately, 
in  many  cases  there  is  no  pregnancy  to  help  us. 

General  Treatment. — The  first  object  is  to  maintain  the 
nutrition  of  the  body  in  a  state  of  activity.  Attention  to 
this  is  specially  required  in  cases  where  there  is  much  gen- 
eral debility,  and  where  it  is  known  or  suspected  that  the 
uterus  is  in  a  condition  of  undue  softness.  Many  months 
may  elapse  before  much  improvement  is  observed  in  regard 
to  this  special  point.  In  a  case  of  chronic  starvation  of 
some  years'  duration  the  nutritional  activity  takes  long  to 
restore.  How  this  is  best  to  be  effected  has  been  already 
described  (see  p.  128).  But  it  must  here  be  stated  that 
experience  renders  it  evident  that  the  secret  of  success  in 
the  treatment  of  chronic  flexions  with  the  uterus  in  a  weak, 
atonic,  soft  condition  is  perseverance  in  careful  feeding. 

There  are  not  a  great  number  of  cases  in  which  care  in 
the  matter  of  nutrition  can  be  dispensed  with.  It  is  not 
rare  to  see  cases  of  chronic  flexion  in  which  the  prostration 
is  so  severe  from  long-continued  semi-starvation  that  it  de- 
mands at  first  almost  exclusive  attention.  The  principal 
malady  for  the  moment  is  in  fact  the  starvation,  and  great 
care  is  required  even  to  save  the  patient  from  perishing 
from  its  effects.  Such  extreme  cases  are  chiefly  noticed 
where  the  flexion  has  set  up  a  chronic  obstinate  vomiting, 
and  the  patient  has  been  thus  effectually  deprived  of  nour- 
ishment for  a  long  time. 

Rest  is  a  most  important  part  of  the  general  treatment, 


DISPLACEMENTS,    DISTORTIONS   OF   THE    UTERUS.    229 

The  indication  is  to  take  off  all  pressure  from  the  uterus. 
The  horizontal  position,  modified  in  various  ways,  best 
effects  this. 

The  extent  to  which  rest  must  be  insisted  on  depends  on 
the  severity  of  the  case.  In  some  cases  it  is  merely  neces- 
sary to  order  the  patient  to  abstain  from  certain  exertions 
and  to  walk  little;  in  others,  on  the  contrary,  no  good  can 
be  done  without  insisting  on  the  most  absolute  rest,  and 
that  to  be  maintained  for  some  time. 

Certain  errors  are  prevalent  in  regard  to  what  constitutes 
rest.  Sitting  in  the  ordinary  position  in  a  chair  with  a  ver- 
tical back  is  not  rest  for  cases  of  flexion  of  the  uterus;  nor 
is  riding  in  a  carriage  rest  under  these  circumstances. 

Rest  is  more  particularly  necessary  at  the  menstrual  pe- 
riods, for  the  troublesome  symptoms  are  then  likely  to  be 
aggravated.  There  are  various  other  precautions  to  take 
which  will  be  suggested  by  reading  over  the  list  of  causes 
of  uterine  flexion  given  at  page  180. 

Experience  has  convinced  me  that  in  chronic  cases  the 
persistent  action  of  the  force  of  gravity  can  be  utilized  very 
largely  by  a  well-adjusted  system  of  rest.  In  cases  where 
mechanical  internal  appliances  are  employed  this  agent 
should  be  carefully  brought  in  as  an  ally  in  the  treatment. 
In  this  way  only  can  some  of  the  difficulties  of  chronic 
cases  be  overcome. 

The  scientific  employment  of  rest  in  association  with 
feeding,  massage,  etc.,  which  has  been  largely  employed  by 
Dr.  Weir  Mitchell  in  America,  and  which  has  been  alluded 
to  in  a  former  chapter,  is  precisely  the  treatment  adapted 
to  the  cases  now  under  consideration. 

The  condition  of  the  bowels  is  always  a  matter  demand- 
ing attention.  The  bowels  should  be  opened  daily,  either 
by  means  of  an  enema,  of  half  a  pint  of  tepid  water  or  a 
minute  dose  of  some  aperient  found  to  suit.  It  is  most 
important  to  prevent  the  straining  and  forcing  liable  to 
occur  when  the  bowels  become  constipated;  and  it  may  be 
assumed  that  such  precautions  will  always  be  required  in 
patients  who  do  not  take  regular  exercise. 

Local  Treatment. — The  first  procedure  to  be  adopted  in 
regard  to  the  local  treatment  is  what  may  be  termed  "  pos- 
tural "  treatment.  Of  late  years  I  have  employed  it  with 
great  advantage,  either  by  itself  or  as  an  assistance  to  other 
local  measures.  In  the  United  States,  Dr.  Campbell,  of 
Georgia,  has   particularly  advocated    the   knee-and-breast 


230 


DISEASES   OF   WOMEN. 


position  in  the  treatment  of  retroflexions  of  the  non-gravid 
uterus.     The  accompanying  figures  illustrate  this  principle 

Fig,  44. 


IV 


*o 


of  treatment.     Fig.  44  is   an   outline  of  the  position  taken 
by  the  patient.     Fig.  45  shows  the  uterus  in  a  retroverted 

Fig.  45. 


position;  the   patient  being  in  the  knee-breast  position  it 
is  evident  that  the  weight  of  the  uterus  will  tend  to  throw 

Fig.  46. 


the  body  of  the  organ  forward.     Fig.  46  shows  the  patient 
in  the  same  position  with  the  uterus  turned  forward  as  just 


DISPLACEMENTS,   DISTORTIONS   OF   THE    UTERUS.   23 1 

described.  Fig.  47  represents  an  air-tube  which  Dr.  Camp- 
bell recommends  to  be  inserted  in  the  vagina  so  as  to  allow 
the  air  to  enter  it,  the  object  being  to  facilitate  the  move- 
ment of  the  body  of  the  uterus  into  its  normal  position. 
The  necessity  for  the  use  of  the  air-tube  has  been  disputed. 
I  have  largely  employed  the  postural  treatment  as  de- 
scribed, but  without  the  air-tube,  and  the  effects  have 
appeared  to  be  satisfactory.  I  have  found  the  knee-and- 
breast  posture  very  serviceable  in  cases  of  uterine  fle.xion, 
whether  backward  or  forward.  The  patient  must  be  di- 
rected to  maintain  this  position  from  two  to  four  or  five 
minutes  several  times  in  the  day,  or  whenever  it  is  con- 
venient to  do  so;  and  this  is  to  be  kept  up  for  some  weeks. 
Postural  treatment  can  of  course  be  carried  out  by  the 
patient  herself,  which  is  an  advantage  in  many  cases  where 

Fig.  47. 


otlier  methods  of  local  treatment  are  inapplicable.  Postural 
treatment  is  not  sufficient  by  itself  in  severe  cases,  but  it  is 
always  available  as  an  adjuvant  to  other  procedures. 

In  cases  of  forward  displacement  of  the  uterus  the  hori- 
zontal position  on  the  back  is  the  best,  the  effect  being 
increased  by  placing  a  pillow  under  the  sacrum.  This 
position  is  the  worst  possible  for  cases  of  backward  dis- 
placement, and  it  is  not  rare  to  meet  with  cases  of  retro- 
flexion rendered  chronic  by  the  patient  having  been  kept 
lying  on  the  back  for  a  considerable  time.  In  cases  of 
backward  flexion  the  patient  must  be  made  as  a  rule  to  lie 
on  the  side,  or  at  all  events  not  on  the  back.  These  points 
will  have  to  be  further  discussed  later  on. 

We  now  come  to  special  methods  of  internal  local  treat- 
ment. 

The  sound  is  an  instrument  by  which  the  shape  of  the 
uterus  can  be  rectified.  A  repetition  of  this  rectification  at 
intervals  is  a  method  of  internal  treatment  of  great  value. 
The  operation  consists  in  carefully  introducing  the  sound 
beyond  the  seat  of  the  flexion,  and  then  gently  turning  it 


232  DISEASES   OF  WOMEN. 

round  so  that  the  concavity  is  turned  the  opposite  way. 
The  sound  should  be  very  slightly  curved,  should  be  gently 
inserted,  and  no  force  whatever  mployed.  By  holding  the 
sound  in  the  uterus  for  a  few  minutes  after  the  flexion  has 
been  reduced  by  its  means,  a  greater  effect  is  produced. 
This  method  of  reduction  may,  if  carefully  done,  be  re- 
peated every  two  or  three  days  if  necessary:  the  plan  offers 
a  means  of  gradually  reducing  an  obstinate  flexion.  It  is 
frequently  found  advisable  to  conjoin  the  use  of  a  pessary 
with  treatment  by  the  sound,  but  the  double  treatment  is 
more  likely  to  produce  irritative  symptoms,  and  if  a  vaginal 
pessary  be  at  the  same  time  worn,  the  frequent  repetition 
of  the  use  of  the  sound  is  not  so  well  borne. 

In  unbending  the  uterus  by  means  of  the  sound,  great 
gentleness  should  be  employed,  and  it  should  be  done 
slowly.  It  is  advantageous  to  use  a  nearly  straight  sound, 
because  the  torsion  of  the  uterus  effected  by  it  is  less.  It 
is  more  difficult,  of  course,  to  introduce  a  nearly  straight 
sound,  but  this  method  of  treatment  should  never  be  em- 
ployed by  any  one  unable  to  thread  an  acute  flexion  with  a 
nearly  straight  sound. 

The  dangers  attendant  on  the  above  treatment  are  irrita- 
tion and  abrasion  of  the  lining  of  the  uterus  and  production 
of  a  quasi-pyaemic  or  actually  pyaemic  process;  great  care 
is  therefore  required  to  avoid  abrasion  or  injury  of  the 
uterine  lining. 

The  "  sound  "treatment  is  not  adapted  for  cases  in  which 
the  uterus  is  very  soft.  It  should  not  be  employed  too  near 
to  the  time  of  the  menstrual  period,  either  before  or  after, 
and  it  is  better  that  the  patient  remain  recumbent  for  half 
an  hour  or  so  after  use  of  the  sound. 

Sound  combined  with  Dilatation. — A  method  of  treatment 
consisting  of  use  of  a  dilating  sound  is  sometimes  very  effec- 
tual. It  is  not  adapted  for  cases  where  the  uterine  canal  is 
very  tortuous,  but  when  it  has  become  tolerably  easy  to 
introduce  a  nearl)^  straight  ordinary  sound,  the  process  now 
to  be  described  can  be  adopted. 

The  instrument  I  employ  for  the  purpose  is  one  which 
has  been  copied  from  a  larger-sized  one,  used  by  the  late 
Dr.  Rigby,  and  made  for  me  by  Coxeter.  The  principle  is 
not  new,  being  that  of  the  glove-stretcher,  but  the  dilating 
blades  are  small  and  can  be  introduced  easily.  After  intro- 
duction they  are  separated  by  a  screw  action,  and  very 
great  force  can  be  made  to  bear  at  the  point  where  dilatation 


DISPLACEMENTS,    DISIUKTIONS    OF   THE    UTERUS.    233 
Fig.  48.*  Fig.  49.* 


*  Figs.  48  and  49  represent  Graily  Hewitt's  Uterine  Dilator.     Fig.  48 
is  a  reduced  drawing.     In  Fig.  49  the  blades  are  shown  the  actual  size, 


234  .  DISEASES   OF  WOMEN. 

is  most  required,  viz.,  the  internal  os.  This  instrument 
must  be  used  with  great  caution  and  care.  The  object  is 
to  gradually  open  out  the  uterine  canal.  This  dilatation 
should  be  effected  at  intervals  of  two  or  more  days,  and 
should  be  slight.  It  is  not  safe  to  effect  dilatation  by  this 
means  unless  the  instrument  can  be  introduced  without 
abrading  the  uterine  canal.  On  the  whole  it  is  safer  also  to 
avoid  using  the  dilator  when  vaginal  pessaries  are  being 
employed. 

The  metallic  dilator  above  described  should  have  a  slight 
groove  cut  on  the  side  opposite  the  small  projection  indi- 
cating the  depth  of  the  uterine  canal.  By  this  means  the 
operator  is  able  to  tell  when  the  instrument  is  properly  and 
sufficiently  inserted. 

The  system  of  dilatation  alDOve  described  is  in  principle 
identical  with  the  gradual  dilatation  by  a  succession  of 
bougies  employed  some  3'ears  ago  by  Dr.  Mackintosh  for  the 
relief  of  dysmenorrhoea. 

A  more  rapid  and  extensive  dilatation  of  the  uterine 
canal  has  been  employed  by  Schultze,  the  object  being  at 
one  operation  to  produce  considerable  enlargement  of  the 
uterine  canal.  The  procedure  consists  first  in  dilating  the 
canal  by  tents,  and  then  forcible  dilatation  is  effected,  by 
means  of  a  two-bladed  instrument,  in  such  a  way  that  the 
structures  of  the  cervix  are  made  to  give  way,  and  a  large- 
sized  canal  at  once  procured. 

The  treatment  of  flexions  by  means  of  the  Uterine  Stem 
must  be  next  considered.  The  object  of  the  use  of  the 
stem  is  to  maintain  a  continuous  reduction  of  the  flexion, 
and  to  keep  the  uterine  canal  straight,  with  the  notion  that 
after  employment  of  this  treatment  for  some  weeks,  or 
months,  or  longer,  the  uterus  will  be  made  to  assume  per- 
manently a  normal  shape,  and  the  uterine  canal  cease  to 
offer  obstruction  to  menstruation  and  to  interfere  with 
other  of  the  uterine  functions. 

With  certain  reservations,  which  will  be  presently  pointed 
out,  there  is  no  doubt  that  the  uterine  stem  treatment  offers 
one  of  the  best  methods  of  dealing  with  cases  of  chronic 
flexion  of  the  uterus.  Many  condemn  the  practice,  and  some 
consider  it  justifiable,  and  reserve  it  for  exceptional  cases. 

There  are  various  methods  of  using  an  intra-uterine  stem, 
some  of  which  are  much  better  and  safer  than  others. 

The  requirements,  according  to  my  own  judgment,  are — 

I.  The  stem  should  be  smooth,  rounded  at  the  extremity, 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    235 

of  an  incorrodible  material,  and  should  not  project  more 
than  one  third  of  an  inch  into  the  cavity  of  the  bod\'  of  the 
uterus — i.e.,  the  whole  length  of  the  stem  should  not  exceed 
if  or  2  inches. 

2.  It  should  be  attached  to  or  connected  with  a  vaginal 
portion,  so  that  the  uterus  as  a  whole  shall  have  its  motions 
controlled  within  certain  limits.  Some  are  in  the  habit  of 
employing  a  simple  uterine  stem,  the  objection  to  which  is 
that  it  only  keeps  the  uterine  canal  straight,  and  does  not 
prevent  the  uterus  from  falling  into  a  state  of  anteversion 
or  retroversion. 

3.  The  uterine  canal  must  be  previously  sufficiently  dilated 
to  allow  of  the  easy  introduction  of  the  stem. 

4.  The  uterus  must  be  in  a  non-irritated  condition. 
Cases  of  retroflexion  are,  as  a  rule,  not  suitable  for  the 

stem  treatment. 

There  can  be  no  question  that  the  uterine  stem  can  be 
quite  safely  employed  by  an  expert  fully  alive  to  the  nature 
of  the  accidents  which  may  occur,  and  who  properly  selects 
the  cases  in  which  to  employ  it;  and  it  is  equally  certain 
that  the  treatment  is  a  great  help  in  the  cure  of  certain  dif- 
ficult cases.  On  the  other  hand,  it  must  be  admitted  that, 
owing  to  the  impossibility  always  of  exercising  the  needful 
supervision,  other  methods  of  treatment  will  very  frequently 
be  preferred.  When  the  uterus  has  attained  to  the  condition 
of  toleration  of  the  stem,  and  it  is  well  fitted,  it  may  be 
worn  without  trouble  of  any  kind  often  for  months  to- 
gether. According  to  my  own  experience  it  is  best  borne 
in  cases  where  the  flexion  is  least  severe;  and  this  is  to  be 
remembered  in  considering  the  question  as  to  the  general 
applicability,  or  rather  as  to  the  general  superiority  of  the 
stem  method  of  treatment.  Again,  when  there  is  great 
parietal  atrophy  as  a  consequence  of  the  long-standing 
flexion,  the  stem  treatment  must  be  continued  for  a  long 
time;  even  after  it  has  been  in  operation  for  a  year  or  so, 
on  removal  of  the  stem  the  flexion  may  be  found  to  return 
almost  as  badly  as  before.  In  some  such  cases  I  have 
found  vaginal  or  extra-uterine  pessaries  to  be  the  only 
practical  method  of  preventing  the  recurrence  of  the  flexion. 
Various  details  as  to  the  application  of  stems  will  be  found 
in  the  chapters  on  Anteflexion  of  the  Uterus. 

Use  of  Tents. — Tents  are  sometimes  employed  as  a  method 
of  curing  flexions  of  the  uterus.  They  offer  a  means  of  di- 
lating the  uterine  canal  and  temporarily  abolish  the  flexion. 


236  DISEASES   OF   WOMEN. 

Tents  have  been  used  both  for  the  purpose  of  procuring 
room  for  the  insertion  of  a  stem,  and  also  for  the  purpose 
of  straightening  the  canal. 

Tents  have  a  temporary  effect  only  on  the  uterus.  They 
might  probably  be  used  at  intervals  for  the  purpose  of 
straightening  the  canal  by  repetitions  of  the  process,  but  it 
does  not  appear  that  one  operation  is  by  itself  of  much 
service  in  the  case  of  a  chronic  flexion,  though  it  may  be 
of  the  greatest  assistance  to  the  carrying  out  of  other 
methods. 

Tents  require  great  care  and  caution  in  their  use.  Details 
respecting  their  employment  will  be  given  later  on. 

Incisions  of  the  Uterine  Caiial. — For  the  cure  of  sterility, 
or  for  the  cure  of  dysmenorrhoea,  the  operation  of  incision 
of  the  uterine  canal  has  been  largely  employed.  This  oper- 
ation is  not  so  largely  in  favor  now  it  is  coming  to  be  better 
understood  that  the  supposed  stricture  of  the  cervical  canal 
is  in  most  cases  due  to  the  uterus  being  flexed.  But  it  has 
also  been  practiced  with  the  express  object  of  facilitating 
the  cure  of  flexion  of  the  uterus,  the  latter  condition  being 
at  the  time  recognized  and  duly  appreciated. 

The  method  adopted  is  to  make  longitudinal  incisions  to 
a  considerable  depth  in  the  cervical  canal,  to  fill  the  en- 
larged canal  at  first  with  a  plug  of  lint,  and  afterward  by  a 
stem.  This  operation  will  be  described  more  in  detail 
later  on. 

Vaginal  Pessaries. — Formerly  vaginal  pessaries  were  em- 
ployed simply  to  prevent  prolapse  of  the  uterus.  They  are 
now  also  employed  with  great  success  in  the  treatment  of 
uterine  flexions. 

It  is  a  very  great  mistake  to  suppose  that  any  pessary 
will  suit  any  case.  If  employed  with  the  view  of  curing  or 
relieving  a  case  of  uterine  flexion  the  vaginal  pessary  must 
be  very  carefully  adjusted  to  the  necessities  of  the  case,  or 
it  will  do  more  harm  than  good.  Dr.  T.  Gaillard  Thomas 
says  on  this  subject:  "A  great  deal  of  experience  is  neces- 
sary before  any  one  can  use  them  with  certainty  of  accom- 
plishing good  results.  A  large  and  varied  assortment  is 
necessary,  and  sufficient  mechanical  ingenuity  to  mould  and 
adapt  to  special  requirements  of  cases." 

The  secret  of  success  in  adjustment  of  a  vaginal  pessary, 
in  the  treatment  of  uterine  flexions  is — (i)  A  right  appre- 
ciation of  the  shape,  size,  and  position  of  the  vaginal  canal. 
(2)  The  use  of  an  instrument  which  shall  not  unduly  dis- 


DISPLACEMENTS,   DISTORTIONS   OF   THE    UTERUS.   237 

tend  the  vaginal  canal,  but  which  shall  exercise  a  constant 
controlling  action  on  the  movements  of  the  body  of  the  uterus. 
No  better  notion  can  be  given  of  the  kind  of  effect  neces- 
sary to  be  produced  than  by  pressing  the  fundus  upward 
by  means  of  the  finger.  Let  us  suppose  the  uterine  body 
can  be  felt  behind  the  cervix  (in  position  of  retroflexion). 
By  pushing  against  this  with  the  finger  it  can  be  made  to 
ascend.  Now  this  is  the  kind  of  action  required  to  be 
effected  by  the  vaginal  pessary,  and  it  has  the  advantage  of 
being  in  constant  operation.  In  the  case  of  anteflexion  the 
pressure  is  required  in  front  of  the  cervix. 

It  generally  happens  that  pressure  is  required  either  in 
front  of  or  behind  the  cervix.  This  pressure  must  have 
a  point  d'appui,  or  basis,  from  which  to  start.  This  is  the 
vaginal  canal,  in  which  the  supporting  agent  must  be 
placed.  Some  vaginal  pessaries  give  pressure  in  a  circular 
manner  all  round  the  uterus,  and  where  the  diagnosis  is  not 
very  exact  such  pessaries  are  better,  or  at  all  events  safer, 
than  others  more  specially  designed  to  give  pressure  in  one 
determinate  direction. 

Vaginal  pessaries  giving  distinct  pressure  (forward  or 
backward,  as  the  case  may  be)  operate  on  the  flexion — (i) 
By  pushing  up  the  fundus;  and  (2)  By  exercising  traction 
on  the  cervix  uteri.  Thus  in  a  case  of  retroflexion  the 
Hodge-shaped  pessary  both  pushes  up  the  fundus  and  draws 
the  cervix  backward.  It  is  a  joint  action,  and  sometimes 
the  effect  is  not  what  is  intended,  because  the  traction  on 
the  cervix  is  too  great  and  the  uterus  is  turned  on  its  trans- 
verse axis  without  being  unbent.  There  are  man}'  details 
connected  with  this  subject  which  will  be  found  later  on. 

By  a  proper  system  of  graduation  in  regard  to  size  the 
effect  of  the  vaginal  pessary  can  be  increased,  if  required, 
from  time  to  time. 

Vaginal  pessaries  with  special  pressure  action  require 
supervision;  otherwise  it  may  happen  that  the  uterus  gives 
way  and  becomes  flexed  in  the  opposite  direction.  This 
can  only  happen  when  the  uterus  is  rather  soft  in  texture. 
It  thus  follows  that  a  vaginal  pessary  may  work  well  for 
three  months,  but  after  that  time  it  may  require  to  be 
readjusted. 

In  flexions  slight  in  degree  and  recent,  a  vaginal  pessary 
alone  is  often  the  only  treatment  required.  If  chronic,  a 
preliminary  treatment  is  necessary,  or  (and  this  is  a  point 
to  which  attention  is  particularly  directed)  it  will  be  neces- 


238 


DISEASES   OF  WOMEN. 


sary  to  keep  the  patient  in  a  state  of  great  quietude,  in  the 
horizontal  position,  until  the  pressure  of  the  support  is  well 
tolerated.  It  is  a  great  mistake  to  apply  a  support  giving 
considerable  pressure  and  at  the  same  time  to  allow  the 
patient  to  go  about  as  usual. 

Postural  treatment  should  be  always  used  conjointly 
with  the  vaginal  pessary  in  severe  cases.  In  most  of  the 
difficult  long-standing  chronic  cases  no  method  has  seemed 
to  me  better  than  conjoint  treatment,  consisting  of — (i) 
postural  treatment,  (2)  use  of  vaginal  pessary,  (3)  use  of 
uterine  sound,  or  uterine  dilator.  This  process  of  cure, 
though  tedious,  seems  the  most  effectual. 

A  point  worthy  of  attention  is  the  necessity  for  aperient 
medicine  or  daily  enemata  in  cases  where  vaginal  pessaries 
are  worn.  It  is  frequently  observed  that  the  natural  action 
of  the  bowels  is  a  little  interfered  with,  and  medicine  or 
enemata  will  then  be  required. 

Another  point  is  the  necessity  for  use  of  vaginal  injections 
in  most  cases  where  vaginal  pessaries  are  worn;  especially 
should  such  injections  be  used  as  the  menstrual  period  is 
coming  to  an  end.  Half  a  pint  of  rather  warm  water  mixed 
with  a  teaspoonful  of  Condy's  fluid  is  the  best  injection  to 
employ. 

As  regards  the  material  of  which  vaginal  pessaries  are 
constructed  something  has  to  be  said.     When  the  pessary 


Fig.  50.* 


has  to  be  worn  some  time,  and  no 
further  change  of  shape  is  required, 
ebonite  is  the  best  material.  Cop- 
per wire  covered  with  india-rubber 
is  a  good  material  because  of  its 
softness  and  pliability.  Cleansing 
injections  are,  however,  more  often 
required.  Metallic  pessaries  are 
sometimes  very  convenient.  Block 
tin  is  a  good  material,  though 
heavier  than  ebonite.  Aluminium  is 
an  excellent  material,  owing  to  its 
lightness. 

Vaginal  tampons  have  been  rather 
largely  used  by  practitioners  in  America  and  elsewhere  in 
the   treatment   of   flexions.     Thus   Dr.   Paul   F.   Munde,  of 

*  Fig.  50  shows  (after  Thomas)  the  position  of  the  tampon  in  the  vag- 
inal canal. 


DI^LACEMENTS,   DISTORTIONS   OF  THE    UTERUS.   239 

New  York,  says:  "The  protracted  wearing  of  astringent 
vaginal  tampons  introduced  daily  offers  for  some  cases  of 
ante-  and  retro-displacement  an  excellent  and,  for  some 
cases  of  procidentia,  almost  the  only  efficient  and  safe 
remedy  for  the  displacement — far  superior  to  all  steadily 
worn  hard  or  soft  pessaries."* 

For  my  own  part  I  have  little  experience  of  the  use  of 
tampons,  but  it  is  easy  to  see  that  they  might  be  of  great 
service,  though  the  necessity  for  daily  attendance  on  the 
patient  which  their  employment  involves  is  a  very  great 
drawback. 

Electricity  has  been  employed  in  Paris  for  the  cure  of 
uterine  flexions,  with  some  success,  and  it  appears  to  me 
likely  that  it  might  be  found  of  great  service  if  persever- 
ingly  and  skilfully  employed.  But  it  could  not  be  expected 
to  do  ver}'^  much  in  long-standing  chronic  cases,  while  in 
the  more  recent  ones  simpler  methods  of  treatment  are 
found  successful. 

General  Sutninary. — A  restoration  of  the  firmness  and 
natural  resistance  of  the  tissues  of  the  uterus  is  required  in 
the  majority  of  cases  where  the  affection  is  recent,  and  in 
many  also  where  it  is  of  long  standing. 

So  long  as  the  uterus  is  deficient  in  these  qualities  it  is 
necessary  to  enforce  a  system  of  rest,  or  else  to  provide 
means — e.g.,  internal  appliances — for  preventing  the  action 
of  gravity  from  reproducing  the  flexion. 

When  the  flexion  is  confirmed  and  the  uterus  hard,  con- 
siderable time  is  required  to  be  spent  in  straightening  it, 
and  prolonged  assistance  by  means  of  internal  appliances 
is  required  after  the  cure  of  the  flexion,  in  order  to  prevent 
the  action  of  gravity  from  reproducing  it. 

Dilatation  of  the  uterine  canal  is  frequently  required  in 
the  latter  class  of  cases.  And  in  some  cases  incision  of  the 
cervix  is  required  in  order  to  facilitate  the  restoration  of 
the  proper  shape. 

Palliative  Treatment. — In  many  cases  it  is  necessary  to 
institute  treatment  for  the  relief  of  the  pain,  irritation,  and 
discomfort  the  patient  is  suffering  from,  irrespective  of,  or 
in  addition  to,  the  measures  required  for  the  cure  of  the 
affection.  Thus,  when  there  is  acute  congestion  of  the 
uterus  the  pain  may  be  very  great.  In  relieving  this  pain 
vaginal  injections  of  hot  water  (temperature  100°  to  110°) 

*  "On  the  Curability  of  Uterine  Displacements,"  p.  24. 


240  DISEASES   OF   WOMEN. 

are  of  great  service.  Dr.  Emmet  strongly  recommends  fre- 
quent use  of  hot-water  injections  in  cases  where  the  uterus 
is  in  a  state  of  irritation,  and  I  have  also  observed  very- 
great  benefit  from  their  employment. 

Opiates  are  most  readily  employed  to  relieve  pain  in  form 
of  suppository,  or  laudanum  with  water  injected  per  rec- 
tum. 

The  congestion  so  frequently  coupled  with  flexion  is 
treated  by  some  practitioners  by  leeches  or  scarifications  of 
the  OS  uteri.  And  there  can  be  no  question  as  to  the  utility 
of  such  local  depletion  in  such  cases.  I  confess,  however, 
that  in  practice  I  find  these  measures  very  rarely  required, 
for  it  is  found  that  when  steps  are  taken  to  relieve  the  em- 
barrassed uterine  circulation  by  elevating  the  fundus  of  the 
uterus,  the  congestion  disappears.  There  are  cases  where 
this  procedure  cannot  be  at  once  effected,  and  in  such  it 
may  be  expedient  to  use  leeches.  But  here  comes  the  ques- 
tion. Are  we  to  wait  for  subsidence  of  congestion  before 
employing  mechanical  resources?  The  reply  to  this  ques- 
tion is,  that  a  well-adjusted  pessary,  together  with  observ- 
ance of  complete  rest  and  a  suitable  postural  treatment,  will 
be  found  not  only  a  possible,  but  a  most  efficacious  method 
in  all  but  a  very  few  cases.  It  is  only  necessary  to  carry 
out  this  plan  of  procedure  to  become  convinced  of  its  pro- 
priety and  suitability.  In  cases  where  the  use  of  a  pessary 
is  postponed,  the  vaginal  tampon  would  be  found  tempo- 
rarily a  suitable  method  of  treatment. 

Counter-irritation  may  be  employed  in  a  variety  of  ways, 
the  plan  selected  being  in  accordance  with  the  peculiar  re- 
quirements of  tlie  case.  A  severe,  sharp,  acute  pain  is  best 
met  by  application  of  a  strong  mustard  poultice  over  the 
hypogastric  region,  or  round  the  loins;  this  is  to  be  re- 
peated at  intervals.  Turpentine  dropped  on  a  piece  of 
flannel  wrung  out  of  boiling  water,  and  applied  to  the  skin, 
is  another  counter-irritant,  even  quicker  in  its  action  than 
the  mustard  poultice. 

Warmth. — Hot  poultices  of  linseed-meal  or  bran  are  most 
valuable  for  the  relief  of  pain  in  all  kinds  of  inflammatory 
affections.  They  should  be  large,  quite  a  third  of  an  inch 
in  thickness,  and  applied  very  hot.  Several  layers  of  flan- 
nel wrung  out  of  boiling  water,  and  rolled  round  the  pel- 
vis, offer  a  ready  means  of  applying  warmth.  The  warm 
hip-bath  may  be  used  for  like  purpose.  Bottles  of  hot 
water,  or  hot  bricks  wrapped  up  in  flannel,  are  household 


DISPLACEMENTS,   DISTORTIONS   OF  THE   UTERUS.    24I 

remedies  of  every-day  use.  A  warm  decoction  of  poppies 
is  often  advantageously  substituted  for  simply  hot  water 
for  fomentations.  The  application  of  cold  is  not  without  its 
uses;  but,  as  an  anodyne,  warmth  is  generally  far  more  ser- 
viceable. 

Anodynes. — The  internal  anodyne  most  ordinarily  availa- 
ble is  opium.  The  "  liquor  opii  sedativus,"  of  Battlcy,  is 
one  of  the  best  forms  in  which  to  use  the  medicine  in  ques- 
tion. Opium  is  often  combined  advantageously  with  some 
of  the  ethereal  preparations.  A  draught  containing  "  Bat- 
tiey"  and  the  compound  spirit  of  sulphuric  ether  is  one  of 
tiie  best  remedies  for  the  relief  of  severe  non-inflammatory 
])ain  referable  to  the  uterus  or  ovaries  which  can  be  em- 
ployed. 

In  chloroform  we  have  an  agent  often  of  great  service. 
Complete  anaesthesia  by  means  of  inhalation  of  chloroform 
is  not  often  required,  except  in  cases  where  pain  is  very 
severe,  or  in  order  to  facilitate  operative  manoeuvres  of  va- 
rious kinds.  Taken  internally,  in  the  form  of  chloric  ether, 
it  is  very  useful  as  an  adjunct  to  opium. 

Belladonna,  hyoscyamus,  and  conium  are  uncertain,  and 
therefore  very  unsatisfactory,  remedies,  for  the  relief  of 
pain,  compared  with  those  just  mentioned.  The  Indian 
hemp  is,  however,  better  entitled  to  consideration,  and  in 
many  cases  undoubtedly  exercises  a  marked  influence  in 
allaying  or  preventing  pain.  Camphor  and  Indian  hemp 
combined  I  have  often  found  of  great  service.  Indian  hemp 
is  a  medicine  which,  so  far  as  my  experience  goes,  appears 
to  effect  different  individuals  very  unequally. 

Camphor,  alone  or  combined  with  opium,  is  of  service 
when  pain  is  spasmodic.  The  various  remedies  known  as 
"antispasmodic"  fulfil  a  like  indication,  and,  as  already  ob- 
served, the  ethereal  preparations  are  most  important  for 
the  relief  of  certain  kinds  of  pain.  The  pain  associated 
with  uterine  contractions,  in  cases  of  difficult  menstruation, 
is  best  influenced  by  the  use  of  antispasmodics.  The  com- 
pound tincture  of  lavender,  chloric  ether,  and  the  compound 
spirit  of  sulphuric  etiier,  may  be  often  very  usefull}^  asso- 
ciated (twenty  drops  of  each  for  a  dose),  opium  being  added 
or  not,  as  may  be  judged  necessary;  this  forms  a  combina- 
tion adapted  for  all  cases  where  there  is  pain  of  a  spas- 
modic character,  whether  at  the  menstrual  period  or  at  other 
times;  this  "red"  mixture  is  one  which  is  very  highly  ap- 
proved of  by  patients. 


242  DISEASES   OF  WOMEN. 

Local  application  of  anodynes  is  often  attended  with  good 
effect.  The  hypodermic  application  of  one  of  the  salts  of 
morphia  is  tlie' most  potent  of  these.  Chloroform  dropped 
on  a  piece  of  lint,  and  applied  over  the  uterine  or  ovarian 
regions,  is  a  remedy  now  and  then  very  useful  for  the  relief 
of  temporary  pains  in  these  regions.  Tincture  of  aconite 
may  be  rubbed  in  with  a  like  object.  Suppositories  or 
enemas,  which  are  in  a  manner  local  remedies,  offer  fre- 
quently a  ready  means  of  relieving  pain  in  the  pelvic  or- 
gans. Solid  opium  may  be  employed  for  this  purpose,  or 
the  tincture  of  opium  suspended  in  water-gruel,  or  mixed 
with  tincture  of  valerian  or  assafoetida;  the  latter  combina- 
tion is  particularly  useful  in  hysterical  cases.  Opiates  and 
sedative  remedies  may  be  also  used  locally,  by  making  them 
up  into  the  form  of  pessaries,  which  are  inserted  in  the 
vaffina. 


CHAPTER   XIX. 

Retroflexion  and  Retroversion  of  the  Uterus. 

Severity  of  the  Affection — Curability. 

Frequency — In  Hospital  and  Private  Practice — Compared  with  Anteflex- 
ion— Single  or  Married. 

Special  Causes— Traumatic  Influences — Dr.  Squarey's  Views — Influence 
of  Bladder — Pregnancy — Straining  Efforts  in  Defsecation. 

Varieties — Basis  for  Classification,  i.  Degree  of  the  Flexion,  first, 
second,  third.  2.  The  Degree  of  Version  (Rotation) — Substitution  of 
Word  "  Rotation"  for  Version — Degrees,  one,  two  and  three.  3.  De- 
gree of  Descent  of  Uterus  as  a  Whole.  4.  Degree  of  Resistance  to 
Replacement  and  Unbending.  5.  Degree  of  Congestion  and  Enlarge- 
ment. 

Progress. 

Cornplications — Adhesions — Congestion — Not  to  be  confounded  with 
Rigidity — Prolapse  of  Ovary — Rupture  of  Perineum — Fibroid  Tumor 
— Prolapsus  of  Rectum. 

Symptoms — Pain,  Dysmenorrhoea,  Menorrhagia,  Leucorrhoea,  Amenor- 
rhoea — Sterility — Abortions — Derangements  of  Bladder,  of  Rectum — 
Reflex  Disturbances. 

Diagnosis. 

The  backward  displacements  and  flexions  of  the  uterus — 
retroversion  and  retroflexion — constitute  a  class  by  them- 
selves, and  may  be  conveniently  considered  together. 

Retroflexion  of  the  uterus  is  one  of  the  most  painful  and 
troublesome  of  the  affections  to  which  women  are  liable. 


RETROFLEXION   AND   RETROVERSION   OF   UTERUS.    243 

The  affection  is  not  always  severe,  it  may  be  a  very  slight 
one — so  much  so  as  to  give  rise  to  no  symptoms  calling  for 
particular  attention;  but  it  is  not  uncommon  to  see  patients 
who  have  been  for  years  tortured  and  incapacitated  by  it  to 
an  extreme  degree,  and  reduced  to  a  helpless  condition  of 
invalidism.  The  obscurity  which  has  surrounded  it  has  not 
even  yet  been  completely  dissipated,  there  being  still  some 
who  deny  the  importance  and  seriousness  of  the  affection; 
so  strong  is  the  effect  of  past  teaching  in  perpetuating  im- 
perfect and  erroneous  views  in  this  as  well  as  in  other  de- 
partments of  medicine. 

Curability. — It  is  well  known  to  those  who  have  paid  at- 
tention to  the  subject  that  retroflexion  of  the  uterus  is  some- 
times so  troublesome  and  severe  in  character  that  it  can 
only  be  cured  by  the  greatest  patience  and  care.  Not  only 
so,  but  cases  are  not  rare  in  which  the  affection  has  been 
pronounced  incurable.  And  more  recently  some  such 
cases,  considered  otherwise  incurable,  have  been  submitted 
to  the  operation  now  known  as  Battley'g  operation,  in  order 
to  relieve  the  patient  of  her  sufferings. 

According  to  my  experience,  however,  the  very  worst 
cases  are  generally  amenable  to  a  judicious  and  patient 
course  of  treatment.  When  the  disease  has  existed  in  a 
severe  form  for  several  years  nothing  can  be  done  in  the 
way  of  permanent  rectification  in  less  than  a  year  or  a  year 
and  a  half;  and  in  such  cases,  when  the  rectification  is  ac- 
complished the  uterus  will  require  artificial  assistance  for  a 
still  longer  time.  I  have  succeeded  in  completely  curing 
many  very  chronic  cases,  the  success  obtained  being  largely 
attributable,  as  I  believe,  to  the  great  attention  paid  not 
unly  to  the  perfect  maintenance  of  the  uterus  in  its  proper 
shape,  but  to  the  restoration  of  the  general  strength  by 
adequate  nutritional  treatment.  I  have  known  cases  where 
success  has  not  resulted  from  mechanical  treatment  owing 
to  neglect  of  the  latter  element  in  the  treatment,  and,  under 
such  circumstances,  it  is  no  wonder  to  me  that  they  should 
be  found  "  incurable." 

Frequency. — The  following  figures  convey  the  results  of 
my  own  observations: 

During  four  and  a  half  years  (1865-1869)  at  University 
College  Hospital,*  out  of  about  1200  cases  prescribed  for  in 
the  department  for  diseases  of  women,  112  were  found  to 

*  These  cases  were  given  in  detail  in  the  3d  edition  of  this  work. 


HA 


DISEASES   OF  WOMEN. 


be  affected  with  retroflexion  and  retroversion.  [Cases  of 
anteflexion  or  -version,  184.] 

During  a  period  of  six  years  of  private  practice  (April 
1873-1879),  out  of  1 140  cases,  180  were  found  to  be  affected 
with  this  distortion  of  the  uterus.  [During  the  same  period 
488  cases  of  anteversion  and  -flexion  were  recorded.]  Thus 
1 140  private  patients  afforded  488  cases  of  anteflexion  as 
against  180  retroflexion,  and  hospital  practice  afforded  out 
of  a  total  of  1200  patients,  184  cases  of  anteflexion  com- 
pared with  112  of  retroflexion.  (For  further  remarks  on 
this  point  see  chapters  on  Anteflexion.) 

Single  or Man-ied. — Retroflexion  of  the  uterus  is  frequently 
observed  in  single  women,  though  the  greater  number  ap- 
plying for  relief  are  found  to  be  married.  Out  of  180  ret- 
roflexion cases  in  private  practice  41  patients  were  un- 
married (227  per  cent.). 

The  following  Particulars  refer  to  180  Cases  in  Private  Practice. 


Age. 

Unmarried. 

Married:  fertile. 

Married:  sterile. 

18 

2  cases 

0 

0 

19 

3      ' 

0 

I 

20 

0      ' 

0 

I 

20-25 

9      ' 

14 

6 

25-30 

12      ' 

21 

19 

30-35 

6      ' 

19 

4 

35-40 

3      ' 

II 

5 

40-45 

4      ' 

15 

I 

45-50 

2      ' 

7 

0 

over  50 

0      ' 

3 

2 

age  not  stated. 
Total. 

— 

7 

3 

41 

97 

42 

180 

Special  Causes  of  Retroflexion. — The  general  question  as  to 
the  causes  of  uterine  flexions  has  been  already  discussed 
(see  p.  179).  The  remarks  there  made  apply  for  the  most 
part  equally  to  cases  of  retroflexion  and  anteflexion. 

Attention  may,  however,  again  be  drawn  to  the  great  fre- 
quency with  wiiich  what  may  be  termed  traumatic  influ- 
ences can  be  shown  to  give  rise  to  this  form  of  displace- 
ment.    In  a  table  given  at  p.  180,  particulars  of  44  cases  of 


RETROFLEXION  AND    RETROVERSION   OF   UTERUS.   245 

retroflexion  in  single  or  sterile  women  are  given.     The  table 

is  to  be  read  in  this  manner: 

There  were  41  sinerle  patients  )      a    •        t 

^         ^  •    J    .     -1        .•     ^    f  suiierms:  from   ret- 
42  married  sterile  patients  V  a     ■ 

.    ,  ,      .,    ^     .      ^    I       roflexion: 
97  married  fertile  patients  ) 

41  -{-  42  =  83  cases  in  whom  child-bearing  had  no  part  in 
the  production  of  the  malady  (7  of  them,  however,  had  had 
abortions).  Now  out  of  these  83  cases  it  was  found  easy  to 
trace  a  traumatic  origin  for  the  retroflexion  in  44  instances. 
In  the  remainder  a  traumatic  influence  was  not  proved  to 
exist,  or  at  all  events  it  was  not  detected.  This  is  an  ex- 
ceedingly important  fact  as  showing  the  frequent  traumatic 
origin  of  the  affection.  And  in  other  cases  where  no  par- 
ticular accident  or  special  exertion  could  be  traced  a  me- 
chanical cause  had  evidenth'  been  in  operation,  acting  more 
continuously  and  slowly,  but  gradually  bringing  about  the 
change  of  shape  and  position. 

It  ma}'  be  inquired.  Are  there  any  special  mechanical 
causes  for  retroflexion  ? — that  is  to  say,  is  any  particular 
force  more  likely  to  produce  a  retroflexion  rather  than  an 
anteflexion?  In  a  very  interesting  paper  bj'  the  late  Dr. 
Squarey  "On  the  Causation  of  Acquired  Flexions  of  the 
Uterus,"*  the  attempt  is  made  to  explain  why  in  some 
cases  flexion  backward  occurs  and  in  others  flexion  forward. 
Dr.  Squarey  suggests  that  it  is  due  to  the  position  of  the 
uterus  at  the  time  of  the  blow  or  shock  or  fall  which  occa- 
sions the  flexion,  and  that  if  the  uterus  be  high  in  the  pelvis 
it  is  more  likely  to  be  pushed  forward,  having  a  natural  in- 
clination in  that  direction  when  high  in  the  pelvis;  whereas, 
if  it  be  low  down  in  the  pelvis,  it  has  a  natural  inclination 
backward,  and  the  force  will  have  the  effect  of  producing 
in  the  latter  case  retroflexion.  There  is  much  to  be  said  in 
favor  of  this  view.  On  looking  at  the  list  of  causes  given 
at  page  180,  where  the  results  of  observations  and  of  in- 
quiries in  340  cases  are  tabulated,  it  will  be  seen  that  vari- 
ous "  traumatic"  influences  (as  Dr.  Meadows  would  term 
them)  were  shown  to  have  produced  in  some  cases  one  form 
of  flexion,  in  others  another.  And  particular  accidents  or 
exertions  seem  to  have  been  tolerably  impartial  in  regard 
to  the  effect  produced.  It  must  be  recollected  that  the 
uterus  in  a  state  of  health  is  well  balanced,  and  a  very  trif- 
ling thing,  the  fulness  or  emptiness  of  the  bladder,  of  the 

*"Obst.  Trans.,"  vol.  xiv.,  1873. 


246  DISEASES   OF  WOMEN. 

rectum — the  position  of  the  body  at  the  moment — or  other 
circumstances,  may  determine  whether  the  fundus  is  to  go 
backward  or  forward. 

It  has  been  shown  (see  p.  167)  that  the  uterus  has  nat- 
urally a  certain  degree  of  what  may  be  termed  "  play"  for- 
ward and  backward,  in  order  to  allow  of  due  action  to  the 
neighboring  viscera.  The  extent  of  this  play  is  not,  prob- 
ably, in  a  state  of  health  very  great.  The  bladder  is  no 
doubt  capable  of  producing  a  considerable  exaggeration  of 
the  natural  movement  of  the  uterine  fundus  backward,  and 
it  is  quite  possible  that  the  fulness  or  emptiress  of  the 
bladder  at  the  moment  when  a  particular  accident  or  shock 
is  sustained  may  be  the  reason  why  the  fundus  is  driven 
violently  downward  and  backward  in  a  state  of  acute  flex- 
ion, whereas  if  the  bladder  had  been  empty  the  result  of 
the  accident  might  have  been  quite  different.  It  is  a  fact  that 
undue  distension  of  the  bladder  may  actually  produce  ret- 
roflexion. In  the  etiological  list  (p.  180)  mention  is  made 
of  one  case  of  this  kind.  In  this  instance,  retention  of 
urine  during  a  railway  journey  produced  retroflexion  of  a 
very  marked  character. 

This  effect  of  bladder  distension  in  causing  (or  rather 
predisposing  to)  retroflexion  must  not  be  confounded  with 
bladder  distension  the  effect  of  retroflexion,  for,  as  is  well 
known,  retroflexion  of  a  large  uterus  may  give  rise  to  dis- 
tension of  the  bladder  and  actual  retention. 

One  important  factor  in  the  etiology  of  retroflexion  ap- 
pears to  be  the  circumstance  that  when  the  uterus  happens 
to  be  bent  backward  there  is  less  power  of  self-rectification 
than  when  it  is  bent  in  the  opposite  direction.  In  the  case 
of  antefl.exion  the  filling  of  the  bladder  may  again  lift  the 
fundus  upward,  but  in  the  case  of  the  retroflected  fundus 
there  is  nothing  to  lift  it  out  of  the  Douglas  pouch,  or  at 
all  events  to  push  it  upward.  The  action  of  the  distended 
rectum  is  not  analogous  to  that  of  the  distended  bladder. 
The  restorative  influences  in  the  case  of  retroflexion  are 
only  the  natural  erectile  resiliency  and  elasticity  of  the 
uterus,  and  possibly  in  some  degree  the  action  of  the  round 
ligaments.  There  is  also  a  possibility  of  a  greater  amount 
of  flexion  in  the  posterior  than  in  the  anterior  direction, 
owing  to  the  depth  of  the  Douglas  pouch  behind  the  uterus. 
I  should  be  inclined  to  think,  judging  from  actual  experi- 
ence, that  in  cases  where  accidents  have  produced  severe 
displacements  the  uterus  must  have  had  an  inclination  for- 


RETROFLEXION  AND    RETROVERSION   OF   UTERUS.   247 

ward  or  backward  at  the  time,  and  that  the  result  of  this 
accident  was  a  great  exaggeration  of  the  previously  exist- 
ing inclination. 

There  can  be  no  question  that  traumatic  influences  are 
capable  of  producing  severe  retroflexion  in  individuals  pre- 
viously in  a  state  of  good  health;  but  it  is  also  certain  that 
general  malnutrition  provides  a  predisposition  of  a  power- 
ful character,  tlie  practical  effect  of  which  is  that  a  weakly 
patient  will  be  more  likely  to  be  injured  by  a  severe  exer- 
tion or  accident  than  one  who  is  strong.  Put  in  this  way 
it  is  a  truism. 

Another  important  class  of  influences  capable  of  produc- 
ing retroflexion  of  the  uterus  is  pregnancy  and  its  effects. 
In  some  few  cases  retroflexion  occurs  for  the  first  time  soon 
after  pregnancy  has  begun;  this  appears,  however,  to  be  a 
rather  rare  event.  Many  women  become  subjects  of  retro- 
flexion after  pregnancy  is  over  who  were  not  affected  with 
it  before.  It  does  not  appear,  however,  that  pregnancy 
has  any  special  effect  in  subsequently  causing  retroflexion 
rather  than  anteflexion.  A  pregnancy  is  not  necessarily 
followed  by  a  flexion  at  all.  It  is  not,  I  believe,  so  often 
followed  by  retroflexion  as  by  anteflexion.  Still  the  fact 
remains  that  we  meet  with  retroflexion  in  women  who  have 
borne  children  and  in  whom  the  retroflexion  is  indubitably 
connected  with  the  previous  occurrence  of  pregnancy. 

Pregnancy  leaves  the  uterus  soft,  large,  heavy,  and  more 
liable  to  be  acted  on  by  the  force  of  gravity.  It  sometimes 
leaves  behind  a  special  predisposition,  viz.,  rupture  of  the 
perineum.  I  find  that  of  180  cases  of  retroflexion  in  pri- 
vate practice  97  were  observed  in  married  women  who  had 
had  children.  In  these  97  cases  traumatic  influences  were 
found  to  have  produced  the  retroflexion  in  a  considerable 
number  of  cases.  The  undue  weight  of  the  uterus,  defi- 
ciency of  the  perineum — are  two  predispositions,  and  a 
walk,  or  strain,  even  the  act  of  straining  at  stool,  may  under 
such  circumstances  produce  suddenly  the  backward  dis- 
placement. Protraction  of  the  period  of  involution  of  the 
uterus,  which  means  generally  extreme  weakness  and  mal- 
nutrition, is  the  precursor  of  retroflexion  in  many  cases. 

One  very  common  cause  of  severe  exaggeration  of  retro- 
flexion is  straining  in  the  process  of  defaecation.  It  is  prol)- 
able  that  such  straining  is  the  primary  cause  in  a  consider- 
able number  of  cases. 

Is   retroflexion   of  the    uterus   ever   congenital  1      My    own 


248 


DISEASES   OF   WOMEN. 
Fig.  51. 


Fig.  52. 


RETROFLEXION   AND   RETROVERSION   OF   UTERUS.   249 

observations  have  not  furnished  me  with  a  single  case. 
Schroeder  gives  the  opinion  that  it  never  occurs.  Grenser, 
in  an  interesting  paper  on  "  Retroflexion,"*  says,  however, 
that  Ruge  in  1875  described  a  case  of  retroflexion  in  a  new- 
ly-born child. 

Varieties  of  Retroflexion. — Four  principal  conditions  offer 
a  basis  for  classification.  One  is  tlie  degree  of  the  bend, 
another  the  amount  of  version  (or  rotation),  a  third  the 
descent  of  the  uterus  as  a  whole,  and  fourth,  the  degree  of 
resistance  which  is  offered  to  the  replacement  of  the  uterus 
in  its  proper  position  and  shape. 

Fir..  ;r 


The  Degree  of  the  FIexio?i. — Flexion  may  be  conveniently 
spoken  of  as  existing  in  three  degrees — the  first  degree 
when  the  axis  of  the  body  of  the  uterus  has  a  relation  to 
the  axis  of  the  cervix  of  about  45°;  the  second  degree 
when  the  angle  is  90°;  and  the  third  when  the  angle  is  be- 
tween 90°  and  135°  or  greater  than  135° — the  uterus  in  the 
latter  case  being  doubled  upon  itself. 

The  accompanying  figures  represent  the  outline  of  the 
uterus  in  these  three  degrees  of  flexion. 

Fig.  51  shows  the  first  degree  of  retroflexion. 

Fig.  52  shows  the  second. 


"Arch,  f,  Gynak."  ii.  p.  145. 


250 


DISEASES   OF  WOMEN. 


The  body  of  the  uterus  is  heavier,  and  its  walls  are  shown 
to  be  thicker  than  normal.  There  is  considerable  conges- 
tion of  all  parts  of  the  uterus,  both  fundus  and  cervix  being 
larger  than  usual.  The  os  uteri  externum  is  widely  open 
and  the  lining  of  the  cervical  canal  partly  everted. 

Fig.  53   exhibits   the  third   stage  of    retroflexion  of  the 
Fig.  54.* 
^1 


uterus  with  much  contraction  and  compressiort  of  the  canal 
at  and  near  the  internal  os  uteri.  There  is  a  very  depend- 
ent position  of  the  fundus  uteri;  there  is  also  considerable 
distension  of  the  cavity  of  the  body  of  the  uterus,  niucli 
swelling  of  the  lips  of  the  os  uteri,  especially  the  posterior 
lip,  and  much  eversion  of  the  cervical  canal  at  the  os  uteri. 

*  Fig.   54  shows  the  second  stage  of  retroflexion,  together   with  the 
second  degree  of  rotation;  the  rectum  and  bladder  are  also  shown. 


RETROFLEXION   AND   RETROVERSION   OF   UTERUS.    25 1 

There  are  other  intermediate  desjrces  of  flexion  possible, 
but  for  practical  purposes  this  subdivision  will  be  sufficient. 
It  is  not  intended  to  imply  that  the  angle  formed  is  repre- 
sented by  straight  lines;  the  uterine  canal  as  a  rule  forms  a 
curve,  no  part  of  it  being  a  straight  line. 

The  Degree  of  Version  {Rotation). — If  the  uterus  were  per- 
fectly rigid,  and  if  its  axis  of  suspension  (a  horizontal  line 

Fig.  55.* 


drawn  transversely  across  the  pelvis  at  the  centre  of  the 
uterus)  were  also  fixed,  the  descent  of  the  fundus  back- 
ward would  imply  necessarily  a  corresponding  elevation  of 
the  OS  uteri.  The  motion  would  be  a  see-saw  motion — as 
the  fundus  descended  the  os  uteri  would  be  elevated — there 
would  be  true   retroversion.      But  the  uterus  is  not  abso- 

*  f 'g-  55  represents  a  third  stage  of  retroflexion  of  the  uterus,  with 
third  degree  of  posterior  rotation;  the  pressure  on  the  rectum  and  drag- 
ging on  the  urethra  are  also  represented. 


252  DISEASES   OF   WOMEN. 

lutely  rigid,  and  when  the  fundus  descends  backward  it 
usually  becomes  bent  above  the  axis  of  suspension,  and 
below  it  also.  The  attachments  of  the  cervix  uteri  prevent 
the  elevation  of  the  os,  so  the  whole  canal  becomes  fiexed. 
The  OS  uteri  has  different  degrees  of  elevation  in  different 
cases.  Three  factors  regulate  this — (i)  The  general  rigidity 
of  the  uterus;  (2)  The  degree  of  fixation  of  the  cervix 
uteri;  (3)  The  mobility  (which  varies)  of  the  axis  of  sus- 
pension of  the  uterus  as  a  whole. 

A  true  notion  of  what  really  happens  to  the  uterus  in 
cases  of  flexion  cannot  be  conveyed  by  using  the  words 
"  version"  and  "  flexion"  only,  for  there  is  another  motion 
to  be  considered — viz.,  the  rotation  of  the  uterus  on  its  axis 
of  suspension  when  in  a  flexed  condition. 

Let  us  suppose  the  uterus  to  be  flexed  backward  in  the 
first  degree  and  incapable  of  flexion  beyond  that  degree. 
If  an  imaginary  fixed  rod  be  passed  transversely  through 
it  at  its  middle,  and  pressure  be  made  upon  the  fundus,  the 
uterus  will  have  a  rotary  motion  imparted  to  it.  The 
flexion  will  not  be  increased,  but  the  fundus  will  descend 
lower  while  the  os  uteri  will  be  elevated.  It  is  possible  to 
have  this  rotatory  motion  with  any  degree  of  flexion,  and 
as  a  matter  of  fact  the  rotatory  movement  in  question  is 
one  of  the  most  important  of  the  clinical  features  of  retro- 
flexion. 

Rotation  may,  and  generally  does,  increase  the  degree  of 
the  flexion,  but  it  is  not  rare  to  meet  with  cases  in  which 
the  uterus  has  become  so  hard  in  its  flexed  state,  that  al- 
though considerable  rotatory  motion  often  occurs,  the  de- 
gree of  the  flexion  is  not  much  increased  thereby. 

In  view  of  the  foregoing  considerations  it  appears  to  me 
desirable  to  substitute  the  word  "rotation"  for  "version" 
in  speaking  of  retroflexions,  more  particularly  as  it  will 
then  be  more  easy  to  give  a  practical  and  clinical  classifica- 
tion of  cases. 

There  are  three  degrees  of  rotation. 

Thus,  when  the  uterus  is  slightly  turned  backward  on  its 
central  transverse  suspensory  axis,  that  will  constitute  the 
first  degree  of  rotation;  when  the  rotation  is  greater,  the 
second  degree;  and  when  the  rotation  is  extreme,  the  third 
degree. 

Rotation  may  be  great  while  flexion  is  very  slight.  Thus 
we  may  have  i^otation  in  third  degree  with  flexion  in  first 
degree.     Such   a  case  as  this  would    be  what   is   usually 


RETROFLEXION  AND  RETROVERSION   OF  UTERUS.   253 

termed  pure  and  simple  retroversion  of  the  uterus,  and  it 
is  a  condition  very  rarely  met  with. 

On  the  other  hand,  rotation  may  be  slight  (first  degree) 

Fig.  56. 


while  flexion  is  great  (third  degree).  But  neither  is  this  a 
very  common  combination.  It  is  more  common  to  meet 
with  the  conjunction  of  rotation  in  the  second  degree,  and 
flexion  in  the  second  or  third  degree. 

Increase  of  rotation  has  a  tendency  to  increase  the  de- 
gree of  flexion,  and  indirectly,  sdso,vue  versd. 


254  DISEASES   OF   WOMEN. 

In  cases  of  retroflexion,  the  degree  of  rotation  is  ever 
liable  to  change.  Exertions  of  various  kinds  increase  the 
degree  of  rotation  for  the  time  being.  The  degree  of 
flexion  is  generally  increased  at  the  same  time,  so  that  the 
displacement diS  well  as  the  distortion  of  the  uterus  is  conjointly 
intensified.  When,  however,  the  exertion  is  at  an  end, 
there  is  a  more  or  less  complete  return  to  the  previous 
condition.  As,  however,  the  return  is  hardly  ever  equal  to 
the  disturbance,  the  tendency  is  to  a  gradual  intensification 
of  both  rotation  and  flexion. 

The  drawing  (Fig.  56)  shows  three  degrees  of  retroflexion 
— first,  second,  and  third. 

After  what  has  been  said,  it  is  hardly  necessary  to  point 
out  that  ascent  of  the  fundus  from  a  low  position  in  the 
Douglas  pouch  does  not  necessarily  imply  a  lessening  of 
the  flexion;  it  may  mean  simply  reduction  in  the  degree  of 
rotation.  The  application  of  this  remark  to  treatment  is 
obvious. 

The  Degree  of  Descent  of  the  Uterus  as  a  Whole. — Men- 
tion has  been  made  of  the  axis  of  suspension.  This  axis 
is  not  fixed,  and  it  is  sometimes  so  little  fixed,  that  the  uterus 
is  allowed  to  fall  very  low — even  to  protrude  from  the 
vulva. 

When  the  uterus  is  very  low  in  the  pelvis  its  shape  is 
more  readily  made  out,  but  the  uterus  may  be  much  dis- 
torted without  falling  very  low.  Asa  rule,  however,  when 
the  distortion  is  great,  the  uterus  is  low.  In  a  very  severe 
case  we  may  have  third  degree  of  flexion,  third  degree  of 
rotation,  and  descent  of  the  uterus  to  the  perineum,  all 
conjoined.  And  in  some  instances  the  whole  uterus  so 
retroflexed  escapes  at  the  vulva  (see  Prolapsus). 

Degree  of  Resistance  to  Replacement  and  Unbending. — Cases 
differ  much  in  this  respect.  The  unbending  and  replace- 
ment may  be  easy,  difficult,  or  very  difficult.  The  sound  is 
used  to  determine  the  degree  of  difficulty. 

When  replacement  is  very  easy,  the  uterus  is  usually  ab- 
normally soft.  When  difficult  or  very  difficult,  the  flexion 
is  usually  of  duration  in  proportion  to  the  degree  of  diffi- 
culty. The  resistance  encountered  arises,  I  believe,  gen- 
erally from  the  acquired  rigidity  of  the  uterus  as  a  whole, 
and  only  very  rarely  from  peritoneal  adhesions.  The  uter- 
us in  chronic  cases  of  retroflexion  is  almost  always  hyper- 
trophied,  and  frequently  becomes  in  time  hard  and  resistant, 
so  that  it  becomes  more  and  more  difficult  to  straighten  it 


RETROFLEXION  AND    RETROVERSION   OF   UTERUS.    255 

as  years  go  on.  But  this  is  by  no  means  constantly  the 
case;  for  I  have  met  with  very  long-standing  retroflexions 
in  single  patients  in  whom  the  uterus  was  found  exceed- 
ingly soft  and  pliable.  Extreme  and  long-continued  mal- 
nutrition has  always  been  a  feature  in  such  cases.  The 
utero-sacral  ligaments  have,  perhaps,  been  occasionally 
taken  for  adhesions.  In  some  few  cases  the  uterus  is  readily 
straightened  owing  to  atrophy  at  the  seat  of  the  bend. 
Long  duration  of  the  malady  does  not  therefore  necessarily 
produce  difficulty  of  restitution. 

Degree  of  Congestion  or  Enlargement. — Retroflexion  of  the 
uterus  is  remarkable  for  the  extreme  degree  of  acute  con- 
gestion which  may  be  associated  with  it.  The  cases  which 
used  to  be  recorded  as  cases  of  acute  inflammation  of  the 
uterus  were  unquestionably  most  of  them  cases  of  severe 
retroflexion  coupled  with  very  acute  congestion;  and  when 
the  acnte  stage  had  passed  away  the  uterus  was  left  in  a 
state  of  chronic  irritability.  Some  of  these  latter  were  en- 
countered by  Gooch,  and  described  by  him  as  cases  of 
"  irritable  uterus."  Congestion  may  exist  in  all  degrees  in 
different  cases.  It  is  most  severe  when  the  flexion  is 
greatest,  and  its  access  in  great  severity  marks  almost  com- 
plete arrest  of  the  circulation  in  the  organ.  The  uterus 
swells,  is  acutely  sensitive,  and  all  motion  is  painful.  In 
other  cases  it  is  less  severe,  and  in  a  few  it  does  not  form 
a  noted  feature  of  the  case.  In  cases  where  the  flexion  is 
only  in  the  first  degree,  but  where  the  rotation  is  not  great 
— such  as  approach  to  version  pure  and  simple — the  con- 
gestion may  not  at  any  period  be  very  intense.  In 
some  such  cases  the  symptoms,  being  slight  in  degree,  have 
given  apparent  foundation  for  the  notion  entertained  by 
some  that  retroflexion  is  an  affection  of  no  clinical  impor- 
tance. One  effect  of  persistent  congestion  is  great  enlarge- 
ment of  the  uterus  as  a  whole,  and  specially  of  the  fundus. 
I  have  found  the  body  of  the  uterus  four  or  five  times  its 
natural  size  in  cases  of  severe  flexion,  and  if  allowed  to  re- 
main in  its  flexed  condition  the  enlargement  is  persistent. 
The  enlargement  due  to  congestion  of  the  retroflexed  fun- 
dus is  sometimes  so  great  that  there  seems  to  be  a  large 
tumor  behind  the  uterus,  and  I  have  more  than  once  been 
misled  by  this,  on  making  a  first  examination. 

The  congestion  affects  the  os  uteri  also,  rendering  it 
swollen,  tumid:  and  as  it  is  engorged  with  blood,  the 
mucous  membrane  of  the  partially  everted  cervix  presents 


256  DISEASES   OF  WOMEN. 

a  highly  vascular  appearance.  Other  important  secondar)' 
changes  occur  (see  Congestion  of  the  Uterus,  p.  no).  Later 
on  the  uterus  is  less  congested,  but  in  a  state  of  chronic  in- 
duration, liable  to  attacks  of  congestion  on  slight  provoca- 
tion. 

Progress. — It  seems  very  possible  that  the  first  step  in 
the  production  of  retroflexion  is  often  a  slight  exaggeration 
of  the  natural  rotatory  motion  in  the  backward  direction; 
next  slight  flexion;  then  increased  rotation  and  increased 
flexion;  and  so  on. 

From  time  to  time  the  flexion  and  rotation  are  increased, 
a  daily  oscillation  at  the  same  time  occurring  in  degree. 
During  the  day  it  is  increased,  at  night  diminished.  The 
affection  remains  a  slight  one,  but  usually  tends  to  become 
severe.  It  may  occur  acutely,  rapidh',  even  instantly,  at- 
taining a  high  degree  of  intensity  (as  from  a  sudden  acci- 
dent), or  in  the  course  of  months  may  gradually  become 
worse  and  worse. 

Having  become  very  severe,  and  the  patient  being  quite 
laid  up  for  some  time  with  it,  a  certain  degree  of  improve- 
ment may  occur,  the  uterus  acquires  some  tolerance  of  its 
distorted  condition,  and  an  incomplete  recovery  follows. 
Slowly  there  is  a  return  to  efficiency,  but  suddenly,  after  a 
few  weeks  or  so,  a  slight  exertion  brings  back  all  the  symp- 
toms with  redoubled  force,  the  flexion  and  rotation  having 
become  suddenly  intensified.  Again  a  rest;  and  again  an  ill- 
ness. 

In  course  of  longer  or  shorter  time  tolerance  may  be  es- 
tablished, the  uterus  has  become  harder,  it  bends  less  on 
motion,  and  a  tolerable  recovery  is  effected.  It  is  not  com- 
mon to  meet  with  this  latter  result  where  the  flexion  passes 
the  second  degree,  or  where  the  rotation  exceeds  the  sec- 
ond degree.  In  the  latter  class  of  cases  recovery  of  efficiency 
(by  which  is  meant  ordinary  capability  for  the  duties  of 
life)  is  very  rare,  and  chronic  invalidism  is  the  rule. 

The  above  statements  apply  to  the  malady  as  observed 
in  cases  where  no  particular  attempt  has  been  made  to 
remedy  the  retroflexion,  and  where  the  disease  has  taken  its 
own  course. 

Marriage  usually  makes  things  worse  for  a  time.  Preg- 
nancy may  occur;  more  often,  perhaps,  does  not.  If  preg- 
nancy occurs  abortion  may,  and  most  frequently  does, 
follow.  If  abortion  does  not  occur,  a  cure  is  for  the  time 
effected.     The  further  history  in  such  a  case  varies;  either 


RETROFLEXION  AND  RETROVERSION  OF  UTERUS.  257 

the  retroflexion  recurs,  becomes  worse,  and  remains  worse, 
or  there  is  a  succession  of  abortions,  or  a  succession  of 
pregnancies  with  occasional  abortions,  or  a  complete  cure. 

Co  plications. — Congestion  of  the  uterus  in  a  most  intense 
form  is  almost  a  part  and  parcel  of  severe  degrees  of  retro- 
flexion. The  congestion  is  the  mechanical  result  of  the 
flexion  (see  p.  112);  it  usually  becomes  increased  in  direct 
proportion  to  the  degree  of  the  flexion  and  rotation.  It  is 
most  intense  in  cases  where  the  flexion  is  in  the  third  de- 
gree, but  the  rotation  in  the  second.  It  is  certainly  less 
severe  in  proportion  as  the  flexion  approaches  the  first  de- 
gree; and  after  some  years  it  sometimes  happens  that  con- 
gestion ceases  to  occur.  Congestion  is  so  common  that  it 
can  hardly  be  considered  as  a  "complication." 

Presence  of  adhesions  is  a  real  complication.  It  appears 
to  be  rare,  but  certain  cases  of  its  occurrence  are  well 
authenticated.  The  fundus  in  such  cases  is  bound  down 
by  peritoneal  bands  in  its  unnatural  position.  The  elevation 
of  the  uterus  by  the  sound,  conjointly  with  the  use  of  the 
finger  in  the  rectum,  is  the  best  method  of  diagnosing 
them,  for  mere  difficulty  in  raising  the  fundus  does  not 
prove  presence  of  adhesions,  as  already  stated  (see  p.  254). 

In  a  paper  by  Dr.  Erich  are  described  "  Seven  Cases  of 
Retroflexion  with  peritoneal  adhesions  of  the  fundus  in 
the  hollow  of  the  sacrum,  treated  by  forcible  separation  of 
the  adhesions;"  *  but  on  reading  the  reports  of  these  cases, 
evidence  of  a  satisfactory  nature  as  to  actual  adhesions  is 
wanting.  The  reports  give  the  notion  that  they  were  cases 
of  rigidity  of  flexion,  rather  than  cases  of  peritoneal  adhe- 
sions. I  have  repeatedh'  found  the  same  difficulty  of  re- 
positing  the  uterus  which  Dr.  Erich  describes;  but,  except 
in  a  few  cases,  I  have  not  had  reason  to  suspect  peritoneal 
adhesions.  The  fact  is,  that  after  a  time  the  uterus  often 
becomes  very  firmly  set  in  its  abnormal  shape.  Forcible 
action  of  the  sound  straightens  it  for  the  moment,  but  the 
flexion  returns  directly.  This  return  of  the  flexion  is  cer- 
tainly not  a  proof  of  adhesions. 

The  utero-sacral  ligaments  sometimes  catch  the  fundus, 
as  it  were,  between  them  in  its  retroflexed  position  (as  Dr. 
John  Williams  has  pointed  out)  and  occasion  an  intensifica- 
tion of  the  congestion.  It  is  evident  that  this  kind  of  in- 
carceration might  give   rise   to  a  suspicion    of  adhesions. 

*  Amer.  Journ.  Obst.,  Oct.,    l88o. 


2S8  DISEASES  OF  WOMEN. 

These  bands  would  be  felt  tightly  on  each  side,  and,  as  a 
matter  of  fact,  these  utero-sacral  ligaments  vary  much  in 
distinctness  in  different  individuals,  and  it  is  only  in  excep- 
tional cases  that  they  are  verj'  strong  and  well  marked. 

Prolapse  of  the  ovarj'  on  one  or  both  sides  is  a  compli- 
cation of  a  very  troublesome  character.  It  does  not  occur 
very  often,  but  when  the  ovary  falls  down  along  with  the 
fundus  uteri  into  the  Douglas  pouch,  and  becomes  adherent 
in  that  position — a  condition  sometimes  met  with — the  case 
becomes  a  very  difficult  one  to  deal  with  in  the  ordinary 
manner.  If  the  ovary  be  not  adherent  the  complication  is 
not  so  troublesome,  and  when  the  fundus  is  replaced  and 
kept  so,  the  ovary  goes  back  into  its  place  also. 

Rupture  of  the  perineum  is  a  complication,  grave  or  not 
according  to  the  degree  of  the  rupture.  The  retroflexion 
is  sometimes  entirely  due  to  the  deficiency  of  the  perinaeal 
support,  and  the  one  cannot  be  cured  without  remedying 
the  other. 

Fibroid  tumor  sometimes  complicates  retroflexion:  a  tu- 
mor growing  at  the  back  of  the  uterus  tilts  the  uterus  back- 
ward, and  constitutes  a  very  grave  complication.  The 
tumor  occasions  most  trouble  perhaps  where  it  is  not  big- 
ger than  an  orange. 

Prolapsus  of  the  rectum  is  sometimes  due  to  the  fundus 
being  pushed  down  into  the  rectum,  partially  inverting  it 
and  forced  partly  out  at  the  anal  aperture  during  attempted 
defaecation.  Here  the  fundus  uteri  acts  as  a  complete  ball- 
valve  in  the  rectum,  and  seriously  interferes  with  its  due 
action. 

SYMPTOMS. 

A  general  account  of  the  symptoms  observed  in  cases  of 
flexions  has  been  already  given  (see  p.  163).  These  symp- 
toms are  observed  in  an  intense  degree — some  more,  some 
less — in  different  cases  of  retroflexion. 

Some  of  these  symptoms  present  peculiarities  in  cases  of 
retroflexion  which  require  to  be  noted. 

The  degree  of  pain  (spontaneous)  is  as  a  rule  greater  in 
retroflexion  than  in  anteflexion,  probably  because  the  de- 
gree of  flexion  is  greater  in  the  former  than  in  the  latter. 
The  pain  is  generallj'  in  the  sacral  region,  but  it  may  be  a 
fixed  pain  on  one  side  of  the  umbilicus,  or  even  higher,  or 
it  maj-  be  in  the  groin.  I  have  met  with  a  few  cases  in 
which  the  pain  has  been  so  situated  as  to  entirely  attract 


RETROFLEXION  AND   RETROVERSION  OF  UTERUS.   259 

attention  away  from  the  uterus  as  the  cause.  I  have  known 
it  to  be  so  persistent  in  this  situation  as  to  have  been  diag- 
nosed to  indicate  cancer  of  the  pylorus.  The  pain  on  loco- 
motion or  movement  (uterine  dyskinesia)  is  often  most 
intense.  This  symptom  is  one  almost  always  very  decid- 
edly and  painfully  well-marked  in  retroflexion  cases.  Any- 
tliing  whicli  gives  the  action  of  gravity  an  opportunity  for 
still  further  rotating  and  bending  the  uterus — as  standing, 
walking,  stooping,  even  sitting — may  give  rise  to  extreme 
torture.  This  symptom  may  be  absent,  or  not  noticed, 
when  the  disease  is  of  slow  growth,  but  in  the  end  it  shows 
itself  in  a  marked  form.  A  not  uncommon  circumstance 
is  to  find  that  a  patient  is  what  is  called  "very  weak." 
This  may  turn  out  on  inquiry  to  mean  that  she  can  walk 
but  little;  and  investigation  shows  perhaps  that  she  does 
not  walk,  because  of  the  discomfort  produced  by  it.  This 
discomfort  finally  is  discovered  to  be  due  to  an  unsuspected 
retroflexion. 

The  sensitiveness  of  the  uterus  to  touch  is  in  very  severe 
cases  most  extravagantly  great.  These  are  the  typical 
cases  of  what  has  been  known  as  "  Gooch's  irritable  uterus," 
the  pathology  of  which  has  been  explained  at  p.  212. 
Chronic  severe  cases  of  retroflexion  are  cases  of  this  kind. 
This  degree  of  sensitiveness  is  not  so  often  found  in  ante- 
flexion cases,  though  it  is  sometimes  met  with.  The  sensi- 
tiveness is  accompanied  with  congestion.  The  part  most 
sensitive  is  the  fundus;  the  os  uteri  is  not  generally  so 
sensitive  to  the  touch  as  the  fundus.  Any  attempt  to  ex- 
amine the  uterus  with  the  finger,  unless  done  with  the 
greatest  care,  causes  the  patient  to  shriek  out;  and  it  is  at 
first  rather  surprising  to  find  the  uterus  so  sensitive  when 
tlie  amount  of  spontaneous  pain  felt  may  not  be  very  great. 
There  is,  I  believe,  always  in  such  cases  considerable  me- 
chanical pressure  on  uterine  nerves,  due  to  the  squeezing 
of  the  tissues  of  the  organ.  Dyspareunia  is  almost  always 
well  marked  in  severe  cases  of  retroflexion. 

Dysmenorrhoea  is  often  severe,  but  as  a  rule  not  so  com- 
mon as  in  anteflexion. 

Leucorrhoea,  appearing  in  the  form  of  gushes,  is  not  un- 
common. A  more  or  less  copious  puriform  discharge  is 
rather  frequently  observed. 

Menorrhagia  is  common.  Patients  with  retroflexion  often 
lose  largely  at  the  periods,  and  there  are  losses  often  at  in- 
tervals   besides.     Large   clots   often    form    in    the   dilated 


26o  DISEASES   OF  WOMEN. 

Uterine  pouch,  and  are  expelled  with  great  pain  and  further 
loss  of  blood. 

Amenorrhoea  is  the  result  in  some  few  cases.  Chronic 
retroflexion  at  first  has  a  tendency  to  increase  the  quantity 
of  menstrual  fluid,  but  after  a  time  in  some  few  cases  it 
ma}'  even  bring  it  to  a  premature  end.  This  latter  result 
is  due  to  the  compression  and  hardening  and  contraction 
the  retroflexed  uterus  in  some  cases  finally  undergoes.  Its 
circulating  apparatus  becomes  in  fact  less  and  less  efficient, 
and  menstruation  ceases. 

Sterility  is  a  common  symptom  (see  p   219). 

Abortions  also  are  common  (see  p.  219). 

The  distiirbajices  of  the  fu fictions  of  the  bladder  due  to  retro- 
flexion are  various.  In  slight  cases  no  disturbance  may  be 
noticed.  In  severe  cases  micturition  is  sometimes  entirely 
impossible  for  a  time,  owing  to  the  dragging  upward  of  the 
meatus  by  the  elevation  of  the  cervix,  or  by  the  actual  com- 
pression of  the  meatus  against  the  pubic  symphysis  by  the 
OS  uteri.  Then  we  have  retention  of  urine.  Sometimes 
micturition  is  more  frequent  than  usual. 

The  rectum  lies  close  to  the  uterus  and  suffers  frequently 
in  cases  of  retroflexion.  The  commonest  symptom  is  con- 
stipation, result  of  actual  compression  of  the  rectum  by 
the  fundus  uteri.  The  more  the  patient  strains  the  greater 
the  difficulty,  because  flexion  is  increased.  Defaecation  be- 
comes also  extremely  painful — it  is  positive  torture  in  bad 
cases.  The  bowel  is  sometimes  in  such  cases  thought  to  be 
diseased  when  it  is  really  quite  sound.  Haemorrhoids  are 
unquestionably  rather  commonly  produced  by  retroflexion. 
A  raw  bleeding  ulcerated  surface  is  sometimes  found  pro- 
duced by  prolapsus  of  the  bowel,  result  of  the  continuous 
straining  efforts  in  the  process  of  defaecation  (see  Com- 
plications, p.  221). 

The  reflex  nervous  symptoms  due  to  retroflexion  are  numer- 
ous, and  they  are  of  the  greatest  importance.  Severe  nau- 
sea, severe  hysterical  symptoms,  are  the  most  marked  of 
these,  but  these  and  other  reflex  sj'mptoms  are  not  peculiar 
to  retroflexion,  and  are  not  therefore  specially  indicative  of 
its  presence.  These  symptoms  are,  on  account  of  their  great 
interest,  reserved  for  consideration  in  a  separate  chapter. 

DIAGNOSIS. 

Diagnosis  is  generally  eas}^  but  in  a  few  cases  difficult. 
It  is  absolutely  impossible  to  certainly  diagnosticate  retro- 


RETROFLEXION  AND   RETROVERSION  OF   UTERUS.   26 1 

flexion  without  a  physical  examination,  many  of  the  symp- 
toms observed  being  liable  to  occur  also  in  anteflexion 
cases. 

The  uterine  fundus  is  readily  felt  from  the  vagina  by  the 
finger:  also  from  the  rectum.  I  have  known  cases  where  it 
has  been  overlooked,  apparently  from  want  of  due  care  in 
placing  the  patient  in  a  favorable  position  for  examination. 
The  lateral  position,  with  the  knees  well  drawn  up,  is  re- 
quired; this  position  allows  the  finger  to  pass  higher  than 
an)^  other.  When  the  flexion  and  rotation  are  only  in  first 
degree,  the  fundus  might  not  be  reached  even  then  by  the 
finger.  When  in  second  or  tliird  degree  it  could  hardly  be 
missed.  The  lower  down  the  uterus  is  as  a  whole,  the 
easier  becomes  the  exploration. 

The  tumor  felt  behind  has  the  shape  of  the  fundus.  But 
not  always  so:  it  may  be  much  swollen.  In  some  rare  cases 
it  is  pyriform,  from  the  fundus  having  been  repeatedly  and 
forcibly  propelled  down  into  the  rectal  aperture.  It  is 
generally  sensitive  to  the  touch.  It  is  of  course  continuous 
with  the  uterine  cervix.  It  can  only  certainly  be  diagnos- 
ticated to  be  the  uterine  fundus — unless  by  an  experienced 
observer — by  using  the  uterine  sound.  Very  gently  and 
carefully  the  sound,  only  slightly  curved,  is  passed,  with 
the  point  directed  backward,  and  if  it  passes  to  the  full 
extent  the  diagnosis  is  established.  In  flexions  of  third 
degree,  especially  with  rotation  to  second  or  third  degrees, 
the  sound  must  be  more  decidedly  bent  in  order  that  it  may 
enter.  Further  the  diagnosis  can  be  carried  by  gently  turn- 
ing the  sound  round  after  so  introducing  it,  when  the  tumor 
generally  can  be  made  to  disappear  and  can  no  longer  be 
felt  by  the  finger.  On  withdrawing  the  sound  the  fundus 
again  descends  unless  the  flexion  be  very  recent. 

The  sound  enables  us  to  distinguish  retroflexion  from 
fibroid  tumor  growing  at  the  back  of  tlie  uterus — a  condi- 
tion which  sometimes  very  closely  simulates  it;  also  from 
a  small  ovarian  tumor  which  might  be  felt  in  the  same  po- 
sition (very  rare);  also  from  tumor  produced  by  haematocele, 
and  from  tumor  due  to  pelvic  cellulitis;  though  the  two 
latter  conditions  could  hardly  be  confounded  with  retro- 
flexion (of  the  non-gravid  uterus  at  all  events);  also  from 
carcinomatous  infiltration  between  the  uterus  and  the  rec- 
tum. 

The  shape  of  the  os  is  peculiar  (as  a  rule)  in  retroflexion. 
It  is  crescentic,  the  posterior  lip  is  longest;  and  it  is  everted, 


262  DISEASES   OF   WOMEN. 

and  often  very  much  swollen.      In   the  nulliparous  uterus 
this  characteristic  shape  of  the  os  is  not  usually  observed. 

The  position  of  the  cervix  is  abnormal.  It  is  more  or 
less  tilted  upward;  sometimes  it  is  quite  high  up  behind 
the  symphysis  and  very  close  to  the  pubic  bones.  The 
vaginal  pouch  behind  the  cervix  is  lost,  owing  to  the  fundus 
pressing  it  downward  and  obliterating  it.  And  there  is  an. 
unnatural  pouch  up  behind  the  symphysis  pubis  in  front  of 
the  cervix.  Moreover,  by  the  double  touch  the  fundus  is 
found  absent  from  its  normal  position. 


CHAPTER  XX. 

Retroflexion  and  Retroversion  of  the  Uterus — 
{Continued?). 

Treatment. — General — Local — Plan  recommended — Outline  and  De- 
tails— Postural  Treatment — Mechanical  Direct  Reposition — Mainte- 
nance of  Proper  Position  by  Vaginal  Pessary — Form  of  Pessary  recom- 
mended— Various  Sizes  required. 

Position  of  Patient — Use  of  the  Sound — Conjoint  use  of  Sound  and 
Pessary — Difficulties  encountered  in  Treatment  of  Cases — Adjustment 
of  Size  of  Pessary — How  far  Vaginal  Pessaries  are  reliable — Action  of 
the  A.  Smith  Modification  of  Hodge  Pessary — Necessity  for  Rest,  and 
gradual  Elevation  of  Fundus  in  some  Cases  — Occasional  Over-action 
of  the  Retroflexion  Pessary — How  long  to  be  continued — Method  of 
Introduction — Change  of  Pessary — Various  Modifications  of  Retro- 
flexion Pessary — Dilatation  and  Moulding  for  Cure  of  Retroflexion — 
Stem  Pessary — Incision  and  Immediate  Rectification — Radical  Opera- 
tion (Koeberle) — Oophorectomy. 

TREATiMENT, 

The  general  principles  of  treatment  of  flexions  laid  down 
at  p.  224  apply  and  should  be  applied  to  the  treatment  of 
this  particular  variety — retroflexion.  It  is  most  iinportant 
at  the  outset  of  the  treatment  that  the  view  taken  of  the 
case  be  as  complete  as  possible,  and  that  l\\&  general  2iX\<\ 
tlie  local  receive  each  their  proper  and  due  share  of  atten- 
tion. 

Premising  that  this  has  been  done,  we  proceed  to  con- 
sider the  various  details  of  the  treatment  of  retroflexion. 

The  Local  Treatment. — There  are  various  plans  adopted  for 
the  treatment  of  cases  of  retroflexion.  The  plan  which  I 
have  found  satisfactory  in  the  large  majority  of  cases  I  pro- 
pose to  mention  first.     It  may  be  described  as  follows: 


RETROFLEXION  AND  RETROVERSION  OF  UTERUS.  iG- 


The  fundus  uteri  is  pushed  upward  from  behind,  rapidly 
or  slowly  according  to  circumstances,  by  means  of  a  pessary 
constructed  on  the  Hodge  principle;  the  pessary  is  kept  in 
situ  persistently  and  the  size  altered  as  circumstances  re- 
quire. The  sound  is  employed  from  time  to  time  to  aid  in 
the  elevation  if  it  be  at  all  difficult.  The  patient  is  kept 
more  or  less  completely  at  rest  until  the  uterus  is  well  in 
its  place,  and  suitably  maintained  there.  Every  advantage 
is  taken  of  the  assistance  of  gravity  in  righting  the  fundus, 
by  the  prone  position,  by  the  knee-and-elbovv  position,  by 

Fig.  57.* 


avoidance  of  the  recumbent-dorsal  position,  by  avoidance 
of  the  sitting  posture,  etc.  The  bowels  are  kept  in  order 
by  daily  injections,  or  otherwise.  Pain  is  relieved  by  opi- 
ates or  by  vaginal  injections  of  hot  water.  Careful  general 
appropriate  treatment. 

The  above  is  an  outline.     The  details   require   further 
specification. 


*  Fig.  57  represents  a  medium-sized  pessary  of  this  kind, 
plan  and  the  sectional  lateral  view  are  given  together. 


The  ground 


264 


DISEASES   OF  WOMEN. 


Direct  Mechanical  Reposiiion. — Regarding  the  condition  as 
entirely  a  mechanical  one,  the  resort  to  mechanical  treat- 
ment is  only  natural.  There  is  no  necessity  to  be  afraid  of 
restoring  an  acutely  congested  retroflexion,  or  of  beginning 
the  attempt  at  all  events,  simply  because  the  uterus  is 
acutely  sensitive  and  in  a  state  of  intense  congestion.  Nor 
is  there  any  necessity  for  depleting  the  uterus   by  leeches 


Fig, 

.58. 

....?i. 

iri'.. 

3. 

m. 

— ••"».... 

Zl 

IN. 

,- 

2i 

IN. 

,*"'' 

■""'-.^ 

2i-_ 

IN. 

,,.- '  ' 

-^-^^^ 

2 

!H. 

\ 


N         \        *• 


before  commencing  the  mechanical  restoration,  seeing  that 
this  restoration  will  pretty  certainly  remove  the  congestion 
(see  p.  137)  as  I  have  observed  over  and  over  again  in  prac- 
tice. The  uterine  fundus  may,  if  very  sensitive,  be  gently 
pushed  upward  by  the  fingers  at  first,  the  postural  treat- 
ment following  it;  or  it  may  often  be  replaced  wholly  or  in 
part  by  the  sound  at  once  if  the  practitioner  is  gentle  and 
skilful  in  its  use.  A  day  or  two  of  postural  treatment  is  a 
good  preparation  for  the  above  measures.     Surprising  re- 


RETROFLEXION  AND  RETROVERSION  OF  UTERUS.  26: 


lief  often  follows  the  elevation  of  the  fundus  in  tlie  acutely 
suffering  cases.  The  pessary  may  be  often  used  at  once, 
pressure  being  made  slight  at  first  and  gradually  increased. 
It  is  absolutely  necessary  at  first  to  maintain  the  recumbent 

Fig.  59.* 


position  if  a  pessary  be  employed  and  the  case  at  all  a 
difficult  one,  or  one  of  long  standing.  The  pessary  I  have 
for  some  time  employed  is  a  vaginal  pessary  on  the  Hodge 
principle.     I   have   for  the  last  three  or  four  years,  in  the 

*  Fig  59  shows  the  action  of  the  pessary  described  in  the  text.  The 
dotted  line  represents  the  position  of  the  uterus  prior  to  the  insertion  of 
the  pessary. 


266  DISEASES   OF  WOMEN. 

majority  of  cases  at  least,  used  a  sliape  nearly  identical 
with  that  known  as  thq  "Albert  Smith"  shape — broad 
above  and  narrow  below. 

From  a  copper  ring  covered  with  india-rubber  an  admira- 
ble instrument  can  be  made.  The  type  of  the  instrument 
is  that  shown  in  Figs.  57  and  60.  It  requires  various  modi- 
fications in  different  cases.  Therefore,  various-sized  rings 
are  required.  A  series  of  rings  ranging  in  outside  diameter 
from  two  inches  to  about  three  and  a  quarter  inches  are 
required  (see  Fig.  58):  the  first  measuring  two  inches,  the 
second  two  and  a  quarter,  the  third  two  and  a  half,  the 
fourth  two  and  three  quarters,  and  so  on  up  to  three  and  a 
quarter  inches.     The  thickness  here  shown  is  five  sixteenths 

Fig.  60.* 


of  an  inch;  other  degrees  of  thickness  are  required  or  may 
be  used  at  the  discretion  of  the  practitioner.  The  copper 
wire  used  should  be  rather  stout  for  the  large-sized  rings — 
rather  thicker  than  for  the  smaller  ones. 

The  thickness  of  ^he  ring  when  covered  with  india-rubber 
may  with  advantage  be  a  quarter  of  an  inch  for  the  very 
small  rings  (instead  of  that  shown  in  the  figure,  which  is 
five  sixteenths),  but  about  five  sixteenths  is  a  good  thick- 
ness for  the  sizes  ordinarily  required.  For  larger  sizes  the 
thickness  may  be  increased  to  six  sixteenths  with  advan- 
tage. 

The  accompanying  drawing  (Fig.  59)  shows  the  retro- 
flexion pessary  of  the  A.  Smith  type  in  situ;  the  drawing  is 
life-size,  the  pessary    shown   in  situ   is   constructed   from  a 

*  Fig.  60  shows  an  oblique  view  of  a  medium-sized  A.  Smith  type 
Hodge  pessary. 


RETROFLEXION  AND  RETROVERSION  OF  UTERUS.  267 

ring  two  and  three  quarters  inches  in  diameter.  The  upper 
curve  of  the  instrument  may  be  modified.  The  curve  I 
generally  employ  is  less  sharp  than  that  depicted  in  some 
American  works,  but  this  is  liable  to  modification  according 
to  the  particular  case. 

In  the  last  edition  of  this  work  are  represented  figures  of 
an  oval-shaped  pessary  rather  larger  at  one  end  than  the 

Fig.  6i. 


other,  the  smaller  end  being  behind  the  cervix  uteri.  But 
I  have  found  the  shape  originally  introduced  by  Dr.  A. 
Smith  to  work  so  satisfactorily  that  I  prefer  it  to  all  others. 
His  modification  of  the  Hodge  pessary  for  retroflexion  is 
broad  above,  narrow  below;  it  has  a  rather  sharply  double 
bent  outline  looked  at  from  the  side,  and  it  is  this  outline 
which  preserves  it  from  slipping  downward.  Roughly 
speaking,  the  instrument  is  a  triangle:  the  base  above  be- 
hind the  cervix  supports  the  fundus,  the  apex  below  should 


268  DISEASES   OF  WOMEN. 

be  so  curved  that  it  lies  on  the  vaginal  floor,  and  does  not 
press  on  the  urethra. 

In  considering  the  Albert  Smith  type  of  the  Hodge  pes- 
sary as  the  best,  I  am  in  agreement  with  several  distin- 
guished gynaecologists,  both  American  and  European. 

Fig.  62. 


876 

Various  sizes  are  required  to  be  used  in  different  cases. 
In  Figs.  61  and  62  are  represented  eight  different  sizes. 
The  extremely  small  and  extremely  large  sizes  are  rarely 
required.  In  single  women  a  narrower  pessary  is  required 
than  in  other  cases.  The  size  will  generally  require  to  be 
altered  as  the  cure  advances,  and  as    the  fundus  rises  up 


RETROFLEXION   AND    RETROVERSION   OF   UTERUS.    269 

to  near  its  proper  position,  for  if  the  case  is  a  chronic  one 
it  is  quite  certain  that  only  a  small-sized  pessary  will  be 
borne  at  first;  the  pessaries  constructed  from  rings  of 
two  and  three  quarters  to  three  or  three  and  a  quarter 
inches  in  diameter  are  most  often  required  for  married  pa- 
tients. The  very  large  sizes,  marked  6,  7,  8,  in  Fig.  62  are 
rarely  required,  but  they  are  sometimes  necessary  when  the 
uterus  is  exceptionally  hypertrophied  as  well  as  retroflexed. 
When  the  swelling  of  the  uterus  has  gone  down,  as  it  may 
do  after  a  few  weeks,  a  smaller  pessary  can  be  employed. 

Position  of  the  Patient. — The  patient  should  lie  not  upon 
the  back,  but  upon  the  side,  or,  still  better,  upon  the  face. 
This  is  effected  by  making  a  kind  of  inclined  plane  with 
pillows  placed  under  the  chest  and  abdomen,  one  arm  being 
placed  quite  behind  the  patient's  back.  By  a  little  manage- 
ment a  very  comfortable  position  is  thus  attained.  The 
result  is,  that  the  weight  of  the  fundus  uteri  is  in  a  great 
degree  thrown  forward  instead  of  backward,  and  great  as- 
sistance in  the  mechanical  treatment  is  thus  afforded.  In 
severe  cases  this  position  of  the  bod}''  is  in  fact  absolutely 
necessary,  and  I  have  seen  patients  who  before  had  been  in 
a  state  of  absolute  torture  while  lying  flat  on  the  back  re- 
stored to  comparative  comfort  by  the  simple  procedure  of 
enforcing  the  position  on  the  face.  The  length  of  time 
during  which  it  is  necessary  to  maintain  this  position  of 
the  body  depends  upon  the  acuteness  of  the  case.  But  when 
there  is  much  irritation  about  the  uterus  it  is  absolutely 
necessary  for  the  patient  to  remain  in  this  position  for  some 
weeks.  The  upright  position  is  destructive  of  progress  in 
the  right  direction.  The  knee-and-breast  position  should 
be  used  several  times  a  day  for  three  or  four  minutes  at  a 
time.  All  exertion  must  be  absolutely  interdicted  for  a 
time, varying  according  to  circumstances.  In  this  manner 
we  carry  out  as  far  as  possible  what  may  be  termed  the 
treatment  of  rest.,  a  most  important  element  in  the  treat- 
ment of  these  cases. 

The  Use  of  the  Sound. — The  method  which  I  recommend  in 
the  treatment  of  a  recent  case  of  retroflexion  is  that  the 
sound,  very  slightly  curved  indeed,  should  be  introduced 
gently  and  gradually  into  the  uterus,  and  then  gently 
turned  round,  so  that  the  concavity  looks  forward,  and  the 
uterus  thus  restored  to  its  proper  shape;  that  the  sound 
should  be  used  once  in  two  or  three  days,  perhaps  at  inter- 
vals of   a   week;  and  that  this  treatment  should  be  com- 


270  DISEASES   OF   WOMEN. 

bined  with  the  continuous  use  of  the  vaginal  pessary.  In 
a  recent  case,  the  use  of  the  sound  is  generally  unnecessary 
for  more  than  a  limited  time,  perhaps  for  a  week  or  two.  In 
a  chronic  case,  where  disease  has  existed  perhaps  for  some 
years,  the  use  of  the  sound  is  necessary  at  intervals  of  a  few 
days,  employed  with  great  care,  extending  over  a  period 
of  possibly  tw^o  or  three  months,  and  we  may  be  obliged  to 
intermit  the  use  of  it  occasionally.  Some  cases  do  not  toler- 
ate the  repeated  use  of  the  sound,  owing  to  occurrence  of 
irritative  symptoms;  and  these  are  more  likely  to  occur  if 
the  vaginal  pessary  is  at  the  same  time  continued  to  be 
worn.  When  the  sound  is  used  for  altering  the  shape  of 
the  uterus  it  should  be  bent  very  slightly;  indeed  it  should 
be  very  nearly  straight.  The  difficulty  of  introducing  the 
sound  is  got  over  by  pushing  up  the  fundus  uteri  by  the 
finger  at  the  same  time  that  the  sound  is  gently  passed 
inward  wath  the  concavity  backward.  Even  in  cases 
where  the  flexion  is  very  acute  the  bend  of  the  sound 
need  not  be  great  if  the  procedure  be  simultaneously 
adopted  of  pushing  up  the  fundus.  The  use  of  the  sound 
alone  is  rarely  attended  with  any  permanent  benefit.  The 
uterus  almost  invariably  returns  to  a  flexed  condition  a  few 
moments  after  the  sound  is  withdrawn.  The  rapidity  wuth 
which  the  flexion  returns  on  withdrawal  of  the  sound  is  a 
useful  indication  as  to  the  difficulty  or  not  of  the  cure. 
The  sound  should  always  be  used  gently  and  held  lightly. 
Force  must  not  be  employed,  for  the  process  of  unbending 
the  uterus  in  a  chronic  case  is  necessarily  a  long  one,  and 
involves  considerable  change  and  stretching  of  the  tissues. 
It  is  very  advantageous  in  many  cases  to  hold  the  uterus  in 
its  proper  shape  by  means  of  the  sound  for  half  an  hour  or 
an  hour  at  a  time. 

Difficulties  in  Regai'd  to  Treatment. — There  is  a  very  striking 
difference  in  regard  to  curability  under  different  circum- 
stances. A  case  of  retroflexion  which  has  only  existed  for 
two  or  three  months,  and  which  is  not  very  acute  in  regard 
to  the  degree  of  flexion,  may  be  cured  in  a  few  weeks.  If 
the  flexion  has  existed  for  two  or  three  years  it  may  be  ex- 
pected that  the  treatment  v/ill  not  be  completely  successful 
under,  perhaps,  six  or  eight  months.  And  in  cases  where 
the  malady  has  existed  for  nine  or  ten  years  the  treatment 
may  not  be  successful  even  in  a  much  longer  time,  in  re- 
moving absolutely  all  effects  of  the  disease.  The  changes 
ip  the  texture  of  the  uterus  itself  are  sometimes  so  great 


RETROFLEXION   AND   RETROVERSION   OF   UTERUS.   2/1 

that  it  is  difficult  to  restore  the  organ  to  its  natural  size  and 
position,  and  its  walls  to  their  natural  tliickness.  And  I 
have  known  cases  in  which  the  long  continuance  of  the  com- 
pression process  on  the  tissues  in  the  posterior  wall  of  the 
uterus  has  left  behind  it  a  neuralgia  of  troublesome  charac- 
ter, even  after  the  shape  of  the  uterus  had  been  restored. 
This  is  what  might  be  expected,  and  it  is  analogous  to 
those  cases  where  inflammatory  processes,  resulting  in  com- 
pression of  nerve  trunks  in  other  parts  of  the  body,  leave 
beliind  them  a  persistent  and  intractable  neuralgia. 

The  first  difficulty  is  the  selection  of  the  method  of  treat- 
ment appropriate  to  the  case.  And  it  is  not  easy  to  lay 
down  precise  rules  on  the  subject.  Some  generalizations 
may,  however,  be  offered  as  an  attempt  to  smooth  the  way 
for  those  who  have  not  had  much  experience  in  the  matter. 

The  resistance  offered  to  straightening  the  uterus  is  of 
great  value  as  an  indication.  If  the  directions  previously 
given  be  attended  to,  and  the  sound  lightly  and  carefully 
used,  the  necessary  information  can  be  obtained.  If  there 
is  any  resistance  to  straightening,  or  if  the  uterus  returns 
to  a  state  of  flexion  immediately  on  withdrawal  of  the 
sound,  it  is  certain  that  treatment  b}'  a  vaginal  pessary 
alone  will  not  be  likely  to  succeed,  and  repeated  use  of 
sound  (or  other  like  methods)  will  be  also  required.  A 
well-fitted  vaginal  pessary  will  do  much;  but  if  the  uterus 
be  set  and  firm  in  its  flexed  condition,  the  only  effect  of  its 
use  will  be  to  prevent  increase  of  rotation  of  the  uterus,  but 
the  flexion  may  remain  unaffected.  And  in  such  cases  the 
patient  remains  imperfectly  relieved,  or  if  relieved,  it  is 
found,  on  taking  out  the  pessary  later  on,  that  the  flexion 
is  as  bad  as  ever.  On  the  other  hand,  if  the  uterus  be  soft 
and  pliable,  easily  replaced  and  remaining  replaced  after 
withdrawal  of  sound  for  two  or  three  minutes,  it  may  be 
assumed  that  the  case  maj'  be  safely  treated  by  vaginal 
pessaries  and  postural  treatment  or  without  necessity  for 
repeated  straightening. 

Then  it  may  be  asked,  Cannot  some  cases  be  treated 
without  a  vaginal  pessary  at  all,  and  by  postural  treatment 
alone  ?  No  doubt  if  we  saw  the  case  in  its  earliest  inception 
the  thing  might  be  done;  but  I  have,  myself,  never  seen  a 
case  at  a  sufficiently  early  stage  to  allow  of  this.  On  the 
other  hand,  I  have  known  of  retroflexion  cases  which  have 
been   treated  by  posture  (lying  on  a  prone  couch  at  all 


2/2  DISEASES   OF   WOMEN. 

events)  for  a  year,  or  upward,  and  which  have  not  been 
cured  thereby. 

The  adjustment  of  vagnial  pessaries  is  a  matter  of  no 
little  difficulty.  I  do  not  mean  the  actual  operation  or  in- 
sertion, but  the  selection  of  the  instrument  to  be  used. 

This  seems  the  place  for  the  discussion  of  the  question  as 
to  the  efficacy  of  vaginal  pessaries  in  treatment  of  retro- 
flexion. 1  have  had  the  greatest  success  with  them,  and 
have  cured  many  very  severe  cases  by  their  aid,  assisted,  as 
above  described,  by  use  of  the  sound.  Their  action  requires 
to  be  carefully  watched  and  adjusted  until  the  uterus  is 
secured  in  a  good  shape  and  position,  after  which  they  give 
little  trouble.  The  upper  extremity  of  the  pessary  must 
carry  the  fundus  up  to  its  proper  place.  In  order  to  do 
this  it  must  be  sufficiently  long.  The  vaginal  pouch  behind 
the  cervix  is  of  course  pushed  up  in  accomplishing  this, 
and  I  have  hardly  ever  met  with  a  case  where  a  sufficiently 
long  pessary  could  not  be  inserted.  The  process  often 
requires  a  little  patience,  and  the  pessary  requires  to  be 
exchanged  for  a  longer  one  from  time  to  time  until  the 
object  is  attained.  The  pessary  must  be  carefully  examined 
when  in  situ  to  ascertain  if  the  work  required  is  actually 
done,  for  sometimes  it  will  be  found  that  the  pessary  is 
simply  imbedded  in  the  concavity  of  the  flexion,  and  is 
doing  not  only  no  good,  but  actual  harm.  One  practical 
direction  may  here  be  given.  Sufficient  care  is  often  not 
given  to  the  method  of  malcing  the  digital  examination. 
If  the  patient  be  properly  placed  with  the  knees  well 
drawn  up,  the  finger  can  be  made  to  reach  nearly  an  inch 
higher  in  the  vagina  than  would  otherwise  be  the  case,  and 
thus  the  displaced  fundus  can  be  felt  more  readily.  This 
is  important  in  testing  the  action  of  the  pessary.  The 
sound  can  of  course  be  used  to  test  the  position  of  the  fun- 
dus; this  requires  to  be  done  carefully,  and  the  sound 
should  be  used  nearly  straight.  In  some  cases  it  is  found 
that  the  pessary  requires  to  be  carried  so  high  up  behind 
the  uterus  that  it  is  difficult  to  reach  the  upper  end  with  the 
point  of  the  finger.  It  is  impossible  to  do  more  than  give 
the  possible  range  of  length  and  size  of  instruments,  for 
each  case  has  a  law  for  itself  as  regards  size  and  shape. 

The  pessary  which  I  have  above  mentioned  (the  Albert 
Smith  variety  of  the  Hodge  pessary)  is  very  successful  in 
getting  over  a  difficulty  I  had  frequenth^  experienced  before 
employing  it.     Retroflexion  of  the  uterus  is  rarely  exactly 


RETROFLEXION   AND    RETROVERSION   OF    UTERUS.    273 

median,  the  fundus  having  generally  an  inclination  to  one 
side.  Hence,  the  fundus  is  found  often  to  slip  to  one  side 
of  the  ordinary-shaped  instrument.  But  when  the  instru- 
ment is  made  wide  above,  as  in  the  Albert  Smith  pessary, 
this  slipping  of  the  fundus  is  prevented.  Sometimes  the 
width  required  to  prevent  such  lateral  deviation  is  consid- 
erable. It  is  difficult  to  introduce  a  wide  instrument  when 
the  vaginal  entrance  is  narrow,  but  in  women  who  have 
borne  children  it  is  quite  practicable.  It  is  sometimes  ad- 
visable to  give  the  upper  limb  a  slight  extra  projection  to 
one  side  or  the  other. 

Fig.  63. 


A  valuable  modification  of  the  retroflexion  pessary  is 
described  by  Dr.  Gehrung,*  consisting  in  giving  the  upper 
part  of  the  pessary  a  central  depression,  so  as  to  prevent 
the  fundus  slipping  to  one  side  of  the  pessary.  The  same 
idea  is  carried  out  in  Dr.  Gervis'  pessary.  Gehrung's 
pessary  is  shown  in  the  accompanying  figure  (Fig.  6;^)  and 
is  peculiarly  useful  in  cases  where  the  uterus  is  really  retro- 
flexed  a  little  to  one  side.  The  principle  of  this  modifica- 
tion is  excellent,  and  I  have  repeatedly  employed  it. 

The  pessary  above  recommended  has  a  double  action:  it 
draws  the  cervix  backward  and  thus  reduces  the  rotation, 
and   it  appears   to  be  considered   by  some  writers  that  the 


*  St.  Louis  Med.  and  Surg.  Join:,  August,  1878. 


2/4 


"DISEASES   OF  WOMEN. 


action  of  the  Hodge  pessary  is  limited  to  this.  But  it  is 
not  so,  and  I  know  from  practical  experience  that  by  the 
direct  pressure  and  lifting  action  of  the  upper  limb  of  the 
pessary  the  fundus  can  be  carried  to  the  necessary  height, 
though  to  accomplish  this  a  rather  long  pessary  may  be 
needed. 

In  some  cases  where  the  uterus  is  very  large,  a  pessary 
of  considerable  size  is  needed  (see  p.  269),  and  unless  one 
of  sufficient  size  be  used  the  uterus  cannot  be  kept  in  place. 

Fig.  64. 


Other  Modifications  of  the  Retroflexion  Pessary. — There  is 
no  doubt  that  in  some  cases  it  is  an  advantage  to  have  the 
upper  part  of  the  pessary  of  considerable  thickness,  as  the 
pressure  is  better  borne,  and  it  acts  mechanically  better; 
say,  the  size  of  the  little  finger  (about  half  an  inch).  An 
expedient  which  has  been  frequently  had  recourse  to  in 
cases  where  the  pressure  of  the  instrument  against  the  fun- 
dus is  badly  borne,  is  to  cover  the  upper  end  with  a  cushion 


RETROFLEXION   AND    RETROVERSION   OF   UTERUS.    27^^ 


/  J 


containing  water  or  air.  Dr.  Priestley's  pessary  (which  is 
a  stem  acting  from  without)  is  arranged  in  this  manner.  I 
have  occasionally  had  pessaries  on  the  Hodge  principle 
covered  with  such  a  cushion  at  the  upper  end.  In  Dr. 
Greenhalgh's  pessary  (see  Fig.  64,  representing  a  medium- 
sized  instrument)  a  similar  object  is  effected  by  an  air-pad, 
or  by  use  of  the  soft  elastic  material  known  as  moc-main 
covered  with  india-rubber. 

In  a  really  troublesome  case  it  would  be  best  to  have  an 
instrument  so  padded,  which  would  admit  of  being  moulded 
into  the  exact  shape  required. 

Practically  I  find  that,  generally,  direct  pressure  on  the 
fundus  can  be  prevented;  and  when  it  cannot,  by  proper 
positional  treatment  and  other  adjuvants,  the  necessity  for 
a  padded  pessary  can  be  often  avoided,  even  when  the  fun- 
dus is  very  tender  to  the  touch. 

Cutter's  pessary  for  retroflexion  is  one  well  worthy  of 
trial  in  cases  where  continuous  pressure  cannot  be  borne. 
It  is  an  ebonite  pessary,  shaped  something  p,^  ^. 

like  the  upper  part  of  a  Hodge  pessary, 
wliich  in  Dr.  Thomas's  modification  of  it  is 
made  rather  thick;  but  the  lower  part  is 
prolonged,  in  a  sigmoid  shape,  and  projects 
at  the  vulva.  At  this  latter  point  it  is  curved 
a  little  back  over  the  perineum,  and  a  tape 
is  thereto  affixed,  curved  upward  over  the 
sacrum,  and  tied  to  a  circular  waist-belt. 
The  pressure  made  on  the  fundus  is  thus 
capable  of  regulation  from  the  outside. 
The  advantages  and  the  disadvantages  of 
tins  treatment  are  obvious  enough.  I  have  seen  cases 
where  the  instrument  would  have  been  applicable  with 
advantage,  but  personally  I  prefer  other  methods  of  treat- 
ment. In  Fig.  65  is  shown  Dr.  Thomas's  modification  of 
the  instrument. 

General  Remarks  on  the  Employment  of  the  Retroflexion  Pes- 
sary.— It  is  sometimes  the  case  that  the  pessary,  though 
well  fitted,  can  be  tolerated  for  not  more  than  a  few  hours. 
The  uterus  will  not  always  bear  to  be  carried  at  once  to  its 
proper  position.  Two  courses  are  open:  to  lessen  the  pres- 
sure by  using  a  smaller  pessary,  or  to  rigidly  enforce  the 
prone  position;  and  both  these  courses  may  have  to  be 
taken  at  the  same  time.  The  pessary  should  be  made  to 
act  as  little  by  direct  pressure  on  the  fundus  as  may  be, 


276  DISEASES   OF  WOMEN. 

and  the  use  of  the  sound  takes  it  away  from  the  pessary. 
The  prone  position  and  the  knee-and-elbow  position  have 
the  same  result  in  a  more  or  less  complete  degree  according 
to  circumstances.  For  these  reasons  if  the  uterus  be  tender 
to  the  touch,  a  pessary  should  not  be  employed  unless  care 
be  taken  by  rest  and  suitable  position  to  lessen  as  much  as 
possible  the  direct  pressure  of  the  pessary  on  the  fundus; 
and  this  is  a  great  part  of  the  secret  of  success  in  difficult 
cases. 

It  does  not  at  all  follow  because  the  pessary  does  well 
for  a  considerable  time  that  it  will  do  so  indefinitely.  In 
fact,  there  comes  a  period  in  some  cases  when,  the  condi- 
tion of  retroflexion  having  been  cured,  the  uterus  is  rotated 
forxvard  by  the  action  of  the  pessary,  and  the  retroflexion 
is  changed  to  an  anteversion  or  flexion.  I  have  seen  cases 
where  much  disappointment  had  been  experienced  in  con- 
sequence of  an  apparent  recurrence  of  symptoms,  and 
where,  on  examination,  this  result  was  found  to  have 
occurred.  It  is  more  likely  to  happen  in  cases  where  the 
uterus  is  rather  soft  than  under  other  circumstances. 
There  are  a  few  cases  where  the  uterus  is  very  soft,  and 
where  the  change  from  retroflexion  to  anteflexion  occurs 
almost  at  once  on  application  of  a  retroflexion  pessary;  but 
they  are  very  rare. 

It  is  difficult  in  some  cases  to  say  when  the  pessary  can 
be  safely  left  off.  This  involves  the  question  as  to  the 
complete  curability  of  retroflexion  of  the  uterus.  When 
pregnancy  occurs,  the  pessary  can  be  removed  at  four 
months,  after  which  time  there  is  little  danger  of  recur- 
rence. After  pregnancy  is  over,  the  pessary  will  probabl}'' 
be  again  required  (in  about  three  weeks),  if  the  distortion 
is  of  long  standing.  On  the  whole,  it  may  be  said  that  if 
the  retroflexion  has  existed  for  two  years  it  will  probably 
be  necessary  to  employ  the  pessary  for  nearly  an  equal 
time.  And,  speaking  generally,  it  would  seem  that  the 
duration  of  the  disease  regulates  pretty  directly  the  dura- 
tion of  the  mechanical  assistance  the  uterus  requires. 
There  are  cases  which  are  more  speedily  cured,  but  they 
are  exceptional.  Pregnancy  certainly  aids  in  the  cure,  but 
does  not  absolutely  effect  it.  After  long  years'  duration, 
a  complete  cure  is  almost  impossible;  though,  by  the  ex- 
penditure of  much  time  and  patience,  the  uterus  may  ulti- 
mately be  made  to  assume  a  correct  form,  even  after  six, 


RETROFLEXION  AND  RETROVERSION  OF  UTERUS.  2;/ 

eight,  or  ten  years;  but  in  such  cases  the  very  prolonged 
use  of  a  vaginal  pessary  will  be  required. 

It  must  be  understood  that  the  pessary  above  recom- 
mended has  no  fixed  bearing  against  any  part  of  the  bony 
framework  of  the  pelvis.  Any  pessary  pressing  against 
the  pubic  bones  is  badly  adjusted,  and  will  be  likely  to  be 
mischievous.  The  pessary  must  be  so  fitted  that  it  is  em- 
braced and  kept  in  place  by  the  vaginal  canal  itself,  which 
embraces  it  and  surrounds  it.  Ordinarily  it  is  not  neces- 
sary to  have  a  broad  base  for  the  instrument,  for  the  sig- 
moid curve  which  it  possesses  seems  admirably  to  insure 
its  retention  in  the  vaginal  canal.  The  lower  extremity  of 
the  pessary  should  therefore  be  just  within  the  vulva  at  the 
centre  of  the  aperture,  and  should  not  press  against  the 
rami  of  the  pubes. 

Introduction  of  the  Retroflexion  Pessary. — The  patient  must 
be  well  placed  on  the  side,  with  the  knees  drawn  high  up. 
The  instrument  should  be  well  covered  at  one  end  with 
cold  cream  or  fresh  lard.  It  should  be  held  a  little  obliquely 
at  the  vaginal  aperture,  as  it  then  passes  in  more  readih\ 
It  is  then  gently  inserted  about  half  way  into  the  canal. 
When  arrived  at  this  point  the  finger  should  be  passed  in 
behind  it,  and  the  upper  extremity  pushed  sliarply  back- 
ward behind  the  cervix.  It  then  shoots  rapidly  into  its 
proper  position.  It  almost  invariably  happens  that  the 
instrument  passes  in  front  of  the  cervix  uteri  instead  of 
behind  it  if  these  precautions  be  not  attended  to,  and  it  is 
hardly  necessary  to  state  that  in  such  a  position  the  instru- 
ment will  do  considerably  more  harm  than  good.  After  it 
is  in  its  place  it  may  be  pressed  firmly  to  make  sure  its 
pressure  can  be  borne;  and  it  is  a  good  plan  to  make  the 
patient  cough  or  to  strain  downward  in  order  to  test  the 
question  as  to  whether  the  pessary  is  so  well  adjusted  that 
it  will  not  escape.  It  is  sometimes  difficult  to  insert  a  pes- 
sary owing  to  tenderness  or  spasmodic  resistance  of  the 
patient,  without  anaesthetic  aid. 

When  the  entrance  of  the  vagina  is  narrow  care  is  requi- 
site to  avoid  bending  the  pessary,  if  made  of  copper  and 
india-rubber,  in  the  process  of  introducing  it.  A  solid 
ebonite  pessary  is  in  such  a  case  better,  unless  the  operator 
is  well  skilled.  It  may  be  well  to  mention  that  the  pessary 
is  worse  than  useless  if  it  be  inserted  with  the  concavity 
downward  instead  of  upward.     No  one  who  has  not  studied 


2/8  DISEASES  OF  WOMEN. 

the    construction   and    objects   of   the   instrument   should 
attempt  to  insert  it. 

Necessity  for  changing  the  Pessary. — A  well-fitted  pessary 
should  require  to  be  changed  very  rarely.  The  object  of 
the  pessary  is  to  maintain  the  fundus  in  its  proper  place, 
and  if  it  be  taken  away  for  purposes  of  cleanliness  it  should 
be  again  at  once  inserted,  otherwise  ground  gained  is  un- 
necessarily lost.  The  pessary  should  be  considered  in  the 
light  of  a  splint,  the  action  of  which  should  be  continuous. 
On  no  account  should  it  be  removed  at  the  catamenial 
period.  If  well-fitted  its  presence  will  at  that  time  be  very 
necessary  and  useful.  If  it  is  thought  serviceable  to  re- 
move the  pessary  for  a  few  days  the  patient  should  not  be 
allowed  to  move  out  of  the  horizontal  position.  For  pur- 
poses of  cleanliness  it  is  sometimes  desirable  to  employ 
daily  injections  of  warm  water  with  a  little  disinfecting 
fluid  when  the  pessary  is  constructed  of  india-rubber;  but 
when  of  ebonite,  injections  are  generally  only  required  just 
after  the  monthly  period  is  over.  Change  of  the  instru- 
ment is  of  course  required  if  it  does  not  fit,  or  when  cir- 
cumstances require  an  instrument  of  a  different  size.  In 
practice  I  have  found  that  patients  go  on  comfortably  wear- 
ing the  same  instrument  sometimes  for  years  together. 
While  writing  this  I  receive  a  letter  from  a  patient  whom  I 
have  not  seen  or  heard  of  for  three  years,  and  who  writes 
to  say  that  she  has  been  perfectly  well  all  the  time,  and 
wishes  to  know  what  to  do,  as  pregnancy  has  now  occurred. 
.It  should  be  the  rule  to  take  note  of  the  condition  of  things 
at  stated  intervals;  not  more  than  a  year  certainly  should 
elapse  without  proper  examination  and  removal  of  the  pes- 
sary; though  in  my  experience  I  have  not  met  with  any  in- 
convenience resulting  from  uninspected  long  protraction  of 
the  use  of  vaginal  pessaries. 

The  Simple  Ring  Pessary  for  the  Treatment  of  Retroflexion. — 
Some  years  ago  Dr.  Meigs  introduced  the  "  ring"  pessary 
for  treatment  of  retroflexion,  and  it  has  been  largely  em- 
ployed for  the  purpose.  The  basis  is  a  piece  of  watch- 
spring.  The  instrument,  as  now  a  good  deal  employed  by 
Dr.  John  Williams  and  others,  is  made  in  various  sizes  and 
covered  thickly  with  india-rubber.  This  pessary  admits  of 
easy  introduction.  Its  merits  are  that  it  is  readily  intro- 
duced, that  it  acts  fairly  well,  and  is  borne  with  less  diffi- 
culty, owing  to  its  elasticity,  than  a  more  rigid  instrument. 
Its  defects  are,  that  it  is  incapable  of  carrying  the  fundus 


RETROFLEXION  AND   RETROVERSION  OF   UTERUS.   27c 


Up  beyond  a  certain  limited  distance,  and  that  the  ring 
must  be  a  large  one  to  do  very  much  in  this  direction;  in- 
volving thereby  undue  stretching  of  the  vagina  transversely. 
It  is,  I  have  found,  most  useful  as  a  temporary  expedient 
in  cases  when  a  more  thorough  treatment  has  to  be  post- 
poned, and   in  a  few  instances  it  is  superior  to  other  pes- 

FiG.  66.* 


saries.  When  thickly  covered  with  india-rubber,  this  pes- 
sary acts  somewhat  after  the  method  of  the  old-fashioned 
disk  pessary. 

Dilatation  and  Moulding  of  the  Ute?-us  as  a  Cure  for  Retroflex- 
ion.— Some  years  ago  Dr.  Moir  of  Edinburgh  suggested  and 
practiced  a  method  consisting  of  dilating  the  uterine  canal 
by  tents  and  the  subsequent  wearing  of  a  stem-pessary;  the 

*  Fig.  66  shows  a  combined  stem  and  Hodge  pessary.  The  shape  of 
the  Hodge  pessary  in  the  above  figure  is  not  the  best  that  could  be  de- 
vised; the  Albert  Smith  type  is  best  modified  according  to  the  require- 
ments of  the  case. 


250  t)lSEASES   OF   WOMEN. 

object  being  to  overcome  the  resistance  and  flexion  by  full 
dilatation  in  the  first  place,  and  use  of  the  stem  afterward 
to  maintain  tlie  straightness.  The  method  is  undoubtedly 
sound  in  principle,  and  could  be  employed  in  chronic  ob- 
stinate cases  with  advantage  (see  later  chapter  on  Methods 
of  Dilating  Cervix  Uteri).  Schultze  *  has  more  recently 
adopted  the  plan  of  dilating  first  by  means  of  tangle  tents, 
and  afterward  injecting  carbolic  acid  or  dilute  iron  solu- 
tion to  promote  contraction.  He  uses  also  a  vaginal  pes- 
sary of  figure-of-eight  shape  to  help  in  restoration.  It  ap- 
pears that  he  has  employed  the  method  in  a  large  number 
of  cases  without  bad  result. 

The  Stem  Treat77ient  in  Cases  of  Retroflexion. — It  has  already 
been  stated  (p.  234)  that  as  a  rule  the  stem  treatment  is 
best  adapted  for  anteflexion  cases.  I  have  occasionally 
treated  cases  of  retroflexion  with  the  aid  of  stems,  and  suc- 
cessfully; but  in  the  large  majority  of  cases  I  have  found 
the  ordinary  plan  the  best.  In  the  last  edition  of  this  work 
was  figured  an  instrument  I  have  used  for  the  purpose.  It 
consists  of  an  ebonite  stem  fitting  into  a  vaginal  pessary  on 
the  Hodge  principle,  so  that  it  has  a  double  action.  My 
own  impression  is  that  the  stem  pessary  should,  if  adopted, 
be  used  in  conjunction  with  the  vaginal  pessary,  as  shown 
in  the  annexed  figure.  It  is  essential  that  the  stem  be  kept 
thoroughly  in  the  canal  of  the  uterus  and  not  allowed  partly 
to  escape,  also  that  it  should  not  touch  the  top  of  the 
fundus,  and  it  is  certainly  less  likely  to  wound  the  uterus  if 
the  fundus  be  at  the  same  time  supported  from  behind  by 
the  aid  of  the  vaginal  pessary. 

Incision  and  Immediate  Rectification. — It  has  been  proposed 
to  incise  the  uterus  from  within  in  order  to  relieve  the  flex- 
ion by  an  operation  which  is  a  modification  of  one  which 
has  been  largely  practiced  by  Dr.  Marion  Sims  for  stricture 
of  the  uterine  canal. 

The  latest  phase  of  this  procedure  is  an  operation  de- 
scribed in  the  '■'Americati Jou?-nal  of  Obstetrics''  June,  1876, 
by  Dr.  Lennecker  of  Chicago,  on  "  The  Surgical  Treatment 
of  Primary  Retroflexion  of  the  Uterus." 

He  appears  to  speak  only  of  retroflexion  occurring  before 
marriage.  The  patient  is  placed  in  lithotomy  position;  he 
then  incises  the  cervix  with  scissors,  front  and  back;  then 
with  narrow  knives  incises  the  uterus   up  to   fundus  latterly 

*  Centralblatt  f.  Gyn.,  No.  3,  1879. 


RETROFLEXION  AND  RETROVERSION  OF  UTERUS.  28 1 

and  anteriorly  (three  incisions),  the  knives,  three  in  number, 
being  of  peculiar  shape,  the  handles  bent  and  adapted  to 
curve  of  canal.  After  sponging  with  iced  water,  cotton  is 
inserted  soaked  in  carbolic  acid  to  cauterize  the  incision. 
This  cautery  is  repeated  in  48  hours  after  use  of  a  two- 
bladed  dilator;  then  repeated  every  third  day  till  twelfth; 
then  once  a  week  for  six  weeks.  Ten  days  after  operation 
a  modified  Hodge  used  for  eight  to  ten  weeks. 

He  has  operated  in  thirteen  cases;  in  all  complete  cure; 
in  three  cases  pregnancy  speedily  followed.  Of  latter:  case 
6,  set.  19,  married  i  year;  case  10,  set.  22,  married  2  years; 
case  II,  aet.  22,  married  6  months. 

It  is  stated  that  all  the  cases  were  cured,  and  that  in  three 
pregnancy  speedily  followed,  but  as  the  ages  of  the  three 
latter  were  respectively  19,  22,  and  22,  the  inference  is  that 
the  retroflexion  was  not  of  long  standing,  and  could  have 
been  readily  cured  by  less  severe  procedures. 

I  have  now  entirely  relinquished  the  use  of  the  air-ball 
and  stem-pessary  described  in  the  last  edition  of  this  work. 

Radical  Operation. — Here  may  be  mentioned  an  operation 
performed  by  Koeberle  of  Strasburg,  March  27,  1869,  for 
the  radical  cure  of  retroflexion  by  gastrotomj^  and  fixation 
of  the  uterus  to  the  anterior  abdominal  wall  by  means  of 
the  broad  ligament,  which,  being  brought  forward,  was 
fastened  to  the  edge  of  the  abdominal  wound.  Dr.  Sche- 
telig,  who  describes  the  operation.*  states  that  the  patient 
recovered,  and  the  displacement  of  the  uterus  was  cured. 
Ttie  patient's  age  was  twenty-five.  The  duration  of  the 
malady  was  2\  years.  The  operation  is  a  curiosity  and  the 
procedure  ingenious,  but  it  obviously  involves  a  confession 
of  deficient  mechanical  resource  of  the  less  dangerous  kind. 

Oophorectomy  (Battey's  operation). — In  cases  deemed  other- 
wise incurable,  the  operation  known  as  Battey's  operation 
lias  been  in  some  instances  practiced.  Such  an  operation 
can  only  be  required  or  considered  justifiable  in  very  ex- 
treme cases.  My  own  experience  is  that  with  time  and  pa- 
tience even  the  worst  cases  are  curable.  It  is  possible  that 
there  may  be  cases  in  which  a  long  course  of  treatment 
would  not  succeed,  but  I  have  not  as  yet  met  with  sucli 
cases.     This  subject  will  be  again  referred  to  in  the  chapter 

*  Dr.  Schetelig,  Ueber  eine  Radicaloperation  zur  Beseitigung  der  Ret- 
roflexio  und  Retroversio  Uteri;  Sep.  Abdr.  a.  d.  Centralblatt  f.  d.  med. 
Wissemch.      1869.  No.  27. 


282 


DISEASES   OF  WOMEN. 


on"Diseases  of  the  Ovaries."  Here  I  may  say,  however, 
that  some  of  the  published  records  of  cases  of  oophorec- 
tomy in  which  chronic  retroflexion  existed  appear  to  me  to 
offer  conclusive  evidence  tliat  the  uterine  displacement 
might  have  been  cured,  and  the  operation  thus  rendered 
unnecessary,  by  further  and  more  patient  efforts  to  cure 
the  retroflexion  of  the  uterus. 

[Dr.  Simpson  was  the  first  to  teach  us  how  to  diagnose, 
and  how  to  rectify  a  retroversion. 

He  passes  his  uterine  sound  to  diagnose  the  position,  and 
then  turning  it  half  a  circle,  the  retroverted  fundus  is  nec- 

FiG.  67. 


essarily  elevated  toward  the  promontory  of  the  sacrum. 
But  this  operation  often  produces  great  suffering  and 
sometimes  haemorrhage,  and  I  have  not  for  many  years 
used  Simpson's  sound  as  a  redresser.  I  have  not  seen  any 
more  serious  accident  from  it.  Some  object  to  the  instru- 
ment and  ostracize  it  altogether,  because  perforation  of  the 
fundus  and  death  have  followed  its  injudicious  use.  I  ob- 
ject to  it  only  as  a  redresser.  Its  principle  of  action  is 
wrong,  and  hence  the  pain  and  suffering  it  produces.  I 
only  wonder  it  has  not  done  greater  mischief.  Let  us  for 
a  moment  look  at  its  modus  operandi. 

Fig.  67  represents  a  retroverted  uterus  with  Simpson's 
sound  introduced  as  a  redresser. 

Now  if  we  turn  the  handle  of  the  instrument  (a)  on  its 
own  axis  half  a  circle,  the  distal  end  will  elevate  the  uterus 


RETROFLEXION   AND    RETROVERSION   OF    UTERUS.    283 

from  its  abnormal  position  to  that  shown  b}'  the  dotted 
figure  {c);  but  in  doing  this  it  will  describe  a  semicircle  of 
but  little  less  than  two  inches  and  a  half  radius,  sweeping 
the  fundus  around  with  the  whole  weight  of  the  organ, 
supported  principally  on  the  very  end  of  the  instrument 
which,  in  its  gyration,  changes  its  point  of  pressure  from 
the  posterior  to  the  anterior  face  of  the  uterine  cavity.     To 

Fig.  68. 


elevate  the  fundus  still  more  we  push  the  handle  (^)  back 
toward  the  perineum,  which  thrusts  the  uterine  end  up- 
ward. 

Is  it  to  be  wondered  at,  then,  that  we  occasionally  meet 
with  patients  who  look  upon  the  uterine  sound  with  the 
most  painful  recollections.''  Seeing  that  an  intra-uterine 
force  was  occasionally  necessary  for  the  rectification  of  this 
malposition,  my  father  devised  the  following  instrument  in 
1856  and  has  used  it  ever  since. 

Its  principle  of  action  is   that  of  elevating  the  fundus  ir^ 


284  DISEASES   OF   WOMEN. 

a  straight  line  instead  of  a  circle,  and  of  supporting  the 
weight  of  the  organ  on  a  disk  at  the  os  tincae  instead  of  the 
distal  end  of  the  instrument  at  the  fundus. 

For  this  it  is  onh'  necessar}'  to  make  a  joint  or  hinge  in 
the  sound,  about  two  inches  from  its  uterine  extremity,  and 
fix  a  disk  or  plate  there,  as  a  point  of  support  for  the 
weight  of  the  uterus. 

For  instance,  let  Fig.  68  represent  a  retroverted  uterus, 
with  a  jointed  sound  (a)  introduced,  the  joint  being  at  the 
OS.  Now  all  that  we  have  to  do  is  to  push  the  mouth  of 
the  womb  downward  and  backward  in  the  posterior  cu/  de 
sac  in  the  direction  of  the  place  which  was  at  the  inception 
of  this  movement  occupied  by  the  fundus.  By  this  manoeu- 
vre the  OS  tincae  describes  the  small  arc  of  a  circle  repre- 
sented by  the  dotted  line  (^/),  while  the  fundus  being  ele- 
vated in  a  right  line  describes  a  larger  one  and  takes  the 
position  {l>)y  the  handle  or  shaft  of  the  instrument  being 
represented  by  the  dotted  line  {c).  If  the  instrument  be 
properly  adjusted  this  operation  is  effected  without  suffer- 
ing to  the  patient  or  injury  to  the  uterus.  If  there  are  ad- 
hesions we  can  measure  very  accurately  their  resistance 
and  extensibility.  This  instrument  is  simply  Simpson's 
sound  with  a  joint  or  hinge  two  inches  from  its  uterine 
extremity,  but  its  modus  operandi  is  very  different.  One 
elevates  the  uterus  in  a  right  line,  the  other  in  a  circle 
to  the  right  or  left;  one  supports  the  weight  of  the  organ 
on  a  ball  or  disk  at  the  os,  the  other  principally  on  the 
point  of  the  sound  in  the  uterine  cavity;  one  elevates  the 
uterus  by  a  power  exerted  on  the  cervix,  the  other  by  a 
like  power  on  the  fundus;  one  seldom  produces  pain,  the 
other  often  does. 

This  instrument  is  sometimes  valuable  in  assisting  us  to 
diagnose  the  relative  position  of  small  tumors  on  or  near 
the  uterus. 

Thus,  suppose  we  have  the  uterus  impaled  with  a  stem 
{a)  at  right  angles  with  the  shaft,  its  body  being  thus  held 
firmly  in  the  centre  of  the  pelvis  with  the  fundus  pointing 
to  the  umbilicus — by  pulling  the  handle  of  the  instrument 
forward  while  it  is  thus  rigidly  fixed,  we  can  draw  the 
body  of  the  uterus  toward  and  very  near  the  inner  face  of 
the  symphysis  pubis;  by  pushing  it  back,  we  can  carry  it 
directly  backward  as  far  as  the  depth  of  the  vagina  and 
the  sacral  promontory  will  allow  it  to  go;  by  turning  the 
handle  from  side   to  side,  we  can  at  will   throw  the   fundus 


RETROFLEXION  AND  RETROVERSION  OF  UTERUS.  2^5 

to  the  right  or  left  as  we  please,  and  all  this  without  in- 
jury to  the  organ  itself,  for  its  whole  weight  is  supported, 
as  before  said,  not  on  the  point  of  the  instrument,  as  when 
we  execute  any  of  these  movements  with  Simpson's  sound, 
but  on  the  disk  at  the  os  tincae;  and  while  we  are  thus 
changing  the  position  of  the  uterus  we  can,  by  a  finger  in 
the  vagina  or  rectum,  and  by  palpation  externally,  deter- 
mine whether  any  suspected  tumor  be  attached  to  the 
uterus  by  sessile  adhesions  or  by  ligament  only;  or  whether 
the  two  be  entirely  separate  and  independent  of  each  other. 

The  intra-uterine  portion  of  the  elevator  is  malleable,  be- 
cause we  may  sometimes  wish  to  curve  it  a  little  to  suit  the 
peculiarities  of  some  special  case. 

Ordinarily  this  stem  should  not  be  more  than  two  inches 
long.  It  should  never  be  long  enough  to  touch  the  fundus 
uteri  by  any  possibility. 

In  its  use  we  should  be  careful  to  keep  the  ball  or  disk 
always  pressed  well  up  against  the  os  tincae,  for  if  it  should 
slip  down  half  an  inch  or  more  we  shall  fail  to  elevate  the 
fundus,  as  the  whole  power  of  the  instrument  will  tlien  be 
expended  only  in  pushing  the  os  tincae  backward  and  doub- 
ling the  cervix  on  itself. 

Almost  every  day  we  have  need  of  the  uterine  redresser. 
Where  we  have  a  chronic  reflexion  with  enormous  hyper- 
trophy of  the  posterior  wall  it  is  almost  impossible  to  re- 
place it  merely  by  manipulation  alone.  In  England  it  is 
the  habit  with  best  practitioners  to  push  the  uterus  back 
as  far  as  possible  with  the  finger  and  then  introduce  a 
Hodge  pessary  or  some  modification  of  it  to  complete  the 
replacement  of  the  organ.  This  is  bad  practice  and  is 
often  attended  with  mischievous  results.  We  should  never 
apply  a  pessary  in  cases  of  retroversion  till  we  have  placed 
the  uterus  in  a  complete  state  of  anteversion,  whether  by 
manipulation  or  by  the  redresser.  Where  the  displacement 
is  of  long  standing  the  uterus  should  be  replaced  by  the 
redresser  every  day  for  two  or  three  days,  after  which  we 
may  insert  a  pessary  of  the  Hodge  order. 

The  pessary  must  be  moulded  and  fitted  to  the  peculiari- 
ties of  the  individual  case.  It  must  not  be  too  large  or  too 
small,  too  long  or  too  short,  too  wide  or  too  narrow,  too 
curved  or  too  straight.  It  must  hold  the  womb  in  its  proper 
position,  rather  anteverted  than  retroverted.  It  must  not 
produce  the  least  feeling  of  discomfort  or  pain.  It  must 
not  press  anteriorly  on  the  neck  of  the  bladder,  nor  pos- 


286  DISEASES   OF  WOMEN.  • 

teriorly  on  the  cervix.  In  short,  if  the  patient  is  conscious 
of  its  presence,  except  in  the  relief  it  gives,  it  must  be 
promptly  removed. 

It  is  dangerous  to  leave  an  instrument  in  the  vagina 
even  for  an  hour  if  it  produce  pain.  Nothing  requires 
more  care  than  the  adjustment  of  a  pessary  for  the  treat- 
ment of  uterine  displacements. 

The  whole  art  of  it  is:  first,  in  replacing  the  uterus  per- 
fectly; and  second,  in  adjusting  an  instrument  to  hold  it 
perfectly  and  comfortably  in  position. 

The  pessaries  should  be  made  of  some  malleable  ma- 
terial, so  as  to  mould  it  to  fit  the  case.  Our  author  uses 
india-rubber  on  a  malleable  copper  wire.  This  is  objec- 
tionable on  account  of  the  disgusting  odor  of  the  rubber. 

Dr.  J.  Marion  Sims  has  used  block  tin  for  this  purpose 
for  twenty-five  years  or  more.  Otto  makes  a  very  cleanly 
instrument  of  celluloid  on  copper  wire.  The  camphor  odor 
is  not  objectionable.  The  ordinary  hard-rubber  pessary  can 
be  bent  in  the  desired  shape  by  greasing  it  and  passing  it 
rapidh'  to  and  fro  through  the  fiame  of  a  spirit  lamp  till  it 
is  soft  enough  to  be  curved  or  moulded  as  we  wish. 

The  patient  should  return  from  time  to  time  to  see  if  the 
instrument  is  answering  its  purpose.  Or  she  should  be 
taught  how  to  remove  and  replace  the  instrument.] 


CHAPTER  XXI. 

Anteflexion  and  Anteversion  of  the  Uterus. 

Importance  of  Anterior  Displacements  and  Flexions  Considered. 
— Frequency  with  which  these  Conditions  give  rise  to  Uterine  Dyski- 
nesia— Great  Frequency  of  this  latter  Symptom  as  observed  in  Practice. 

Definition. — Difficulty  hitherto  Experienced  in  Definition — Owing  to 
Existence  of  slight  Anteflexion  in  normal  Uterus — Owing  also  to  Mis- 
apprehension of  true  nature  of  Congestion  of  Uterus  associated  with 
Anteflexion — Author's  Definition:  Exceptional  Cases  when  the  Defini- 
tion does  not  apply — Use  of  the  Finger  in  making  the  necessary  Ex- 
ploration—  Precautions  to  take. 

Etiology. — Predisposing  Causes — Discussion  of  Schultze's  views  as  to 

Movement  of  Uterus  when  Bladder  is  Emptied — Author's  Dissent  from 

Schultze's  Conclusions — Importance  of  Softness  of  Uterine  Tissues  and 

want  of  Rigidity  as  Causing  Anteflexion — Previous  Pregnancy — Rup- 

.  ture  of  Perineum — General  Physical  Weakness  and  Prostration — Spe- 


ANTEFLEXION   AND   ANTEVERSION    OF   UTERUS.   28/ 

cial  or  Exciting  Causes:  Traumatic  Causes,  their  great  Frequency — 
Previous  Attacks  of  Parametritis — Schultze's  "  Pathological  Anteflex- 
ion"— General  Perimetric  Fixation  result  of  Anteflexion  of  long 
standing. 

The  anterior  displacements  and  flexions  of  the  uterus  are 
real  and  serious  ailments,  although  there  are  not  wanting 
authorities  who  dispute  this  view. 

At  the  present  day,  however,  many  gynaecologists  of  re- 
pute recognize  the  importance  of  anterior  displacements  of 
the  uterus.  The  growing  feeling  of  the  importance  of  these 
maladies  is  shown  in  the  fact  that  very  numerous  mechan- 
ical appliances  have  been  recommended  for  their  relief. 

In   reference  to  the  question  as   to  the  "  importance"  of 

Fig.  69.* 


these  affections  it  will  be  found  on  considering  the  matter 
that  the  question  really  at  issue,  but  which  many  who  have 
discussed  it  have  not  thought  it  worth  while  even  to  allude 
to,  is  this:  Taking  the  case  of  a  patient  who  is  suffering 
from  symptoms  referable  to  the  uterus,  what  is  the  actual 
explanation  of  the  pain  or  discomfort,  or  particular  symp- 
tom, which  induces  the  patient  to  seek  medical  advice  in 
such  cases  ?  Having  for  many  years  systematically  en- 
deavored to  procure  an  answer  to  this  question  in  every  in- 
dividual case  which  has  come  before  me,  I  have  arrived  at 
the  conclusion  that  anteversion  and  anteflexion  are  maladies 
having  a  very  high  degree  of  "importance."     The  general 

*  Fig,   69  shows  a  very  marked  case  of  anteflexion.      The    drawing 
represents  a  specitpen  from  University  College  Museum. 


2855 


DISEASES   OF  WOMEN. 


considerations  which  have  led  me  to  arrive  at  this  conclu- 
sion may  be  stated  as  follows: 

In  the  first  place,  attention  must  be  directed  to  the  great 
frequency  with  which  patients  coming  to  consult  us  com- 
plain of  pain  or  discomfort  of  various  kinds  07i  motw?i.  In 
the  chapter  on  Symptomatology  this  subject  has  been 
fully  discussed.  The  analysis  of  this  symptom,  which  I 
have  designated  "uterine  dj'skinesia"  shows  clinically  in 
the  most  conclusive  manner  its  dependence  on  an  exagger- 
ated motion  or  mobility  of  the  uterus  in  one  direction  or 
another;  and  a  multitude  of  observations  extending  now 
over  many  years  has  proved  to  me  that  the  generalization 

Fig.  70.* 


is  a  sound  and  a  true  one.  Further,  it  can  be  abundantly 
shown  from  clinical  evidence  that  sufferings  coming  under 
this  head  constitute  the  large  proportion  of  the  complaints 
of  patients  seeking  advice.  Here  we  have  therefore  two 
points  of  importance:  (i)  That  certain  mechanical  motions 
of  the  uterus  give  rise  to  pain  and  suffering;  and  (2)  that 
such  mechanically  produced  pains  constitute  the  greater 
part  of  the  affection  present.  For,  in  the  patient's  estima- 
tion at  all  events,  what  she  feels  is  to  her  the  disease. 

In  the  next  place,  an  extended  observation  has  shown 
that  there  is  a  very  close  connection  between  certain  de- 
grees of  anteversion  or  flexion,  and  marked   uterine  dys- 

*  Fig.  70  exhibits  acute  anteflexion  of  the  uterus  in  profile,  sectional 
view,  become  chronic. 


ANTEFLEXION  AND   ANTEVERSION   OF   UTERUS.   289 

kinesia,  and  that  the  latter  is  almost  invariably  associated 
with  the  former  (unless  in  cases  where  the  flexion  or  dis- 
placement is  in  the  backward  direction).  A  definite  symp- 
tom is  thus  found  to  indicate  so  generally  a  definite  condi- 
tion of  the  uterus  that  it  is  obviously  a  relation  of  cause 
and  effect. 

A  further  set  of  proofs  consisted  in  observation  of  the 
effects  of  rest,  maintenance  of  the  uterus  in  its  proper  shape 
and  position,  etc.,  in  removing  or  alleviating  this  particular 
set  of  symptoms.  This  effect  is  most  marked,  and  here 
again  observation,  repeated  over  and  over  again,  has  shown 
that  these  symptoms  of  which  the  patient  complains  so 
much  give  way  to  a  treatment  which  is  essentially  a  me- 
chanical one;  and  cease  in  direct  proportion  to  the  success 
of  the  measures  taken  for  preventing  and  restraining  the 
abnormal  movements  of  the  uterus,  and  for  restoring  the 
organ  to  its  proper  shape. 

It  is  thus  by  observations,  repeated  day  after  day,  for 
some  years  past,  and  which  may  in  one  sense  of  the  word 
be  termed  "experimental,"  that  conviction  has  followed  as 
to  the  real  and  substantial  influence  exercised  by  antever- 
sion  and  flexion  of  the  uterus  in  the  production  of  the  pain, 
suffering,  and  discomfort  of  various  kinds  of  which  patients 
so  commonly  complain. 

The  same  reasoning  and  the  same  conclusions  apply  to 
retroversion  and  retroflexion,  and  the  foregoing  statement 
concerns  the  posterior  equally  with  the  anterior  displace- 
ments of  the  uterus.  The  reason  for  making  the  state- 
ment, in  this  place,  is  that  while  retroflexion  and  retrover- 
sion are  admitted,  with  very  few  exceptions,  to  be  maladies, 
it  is  not  so  in  regard  to  anteversion  and  anteflexion:  and  I 
desire  to  point  out  how  and  why  it  is  that  I  have  been  led 
to  regard  the  latter  as  substantial  and  important  affections. 

It  is  not  intended,  in  the  foregoing  remarks,  to  imply 
that  "uterine  dyskinesia"  is  the  only  severe  symptom  in 
cases  of  anterior  flexion.  Other  symptoms  are  important 
also,  but  they  are  better  known,  and  duly  recognized  as 
such,  by  those  who  have  given  attention  to  the  subject. 

Definition. — It  is  now  necessary  to  give  a  definition  of 
anteflexion  and  anteversion. 

The  question  resolves  itself  into  this:  What  degree  of 
anterior  flexion  or  anterior  version  is  to  be  considered 
abnormal  ? 

The  particular  point  at  which  I  find  myself  at  issue  with 


29b  DISEASES   OF  WOMEN^ 

some  writers  and  practitioners  of  repute  is  in  regard  to  the 
importance  of  the  lesser  degrees  of  anterior  flexion  and 
version,  and  their  capability  of  producing  symptoms  of  a 
troublesome  character.  The  basis  of  my  conclusion  is,  as 
already  stated,  a  prolonged  series  of  clinical  observations 
on  tliis  subject. 

With  reference  to  the  more  severe  degrees  of  anteflexion  and 
version  the  number  of  scientific  observers  who  recognize 
their  importance  is  very  considerable.  There  are  onh'  a 
few  left  who  still  deny  the  practical  significance  as  diseases 
of  the  more  severe  cases  of  anterior  displacement.  As  re- 
gards the  importance  of  the  less  severe  degrees  of  anterior 
flexion  and  version  the  number  of  converts  still  to  be  made 
is  more  considerable. 

There  can  be  no  doubt  that  the  principal  cause  of  the 
reluctance  to  recognize  the  anterior  displacements  as  dis- 
eases, is  the  notion  that  inasmuch  as  the  uterus  has  a  slight 
normal  curvature  and  inclination  forward,  further  degrees 
of  that  curvature  and  inclination  forward  cannot  have  any 
practical  importance.  The  prevalence  of  this  notion  is  and 
has  been  so  great  that  few  have  taken  the  trouble  to  differ- 
entiate the  various  degrees  of  anteflexion  and  anteversion. 

This  is  not  the  only  reason  for  the  neglect  which  the  sub- 
ject has  received.  Another  reason  has  been  the  complica- 
tion of  congestion  of  the  uterus  so  frequently  met  with  in 
these  cases,  which  complication  has  received  exclusive  at- 
tention, while  the  displacement  has  been  either  not  recog- 
nized at  all  (as  is  most  commonly  the  case),  or,  if  recog- 
nized, has  been  regarded  as  an  affair  of  quite  secondary 
importance.  Having  had  frequent  opportunities  of  meet- 
ing practitioners  in  consultation  in  cases  of  this  kind,  I 
have  formed  the  conclusion  that  one  reason  why  so  little  is 
known  as  to  the  frequency  and  effects  of  anterior  displace- 
ments is  that  the  very  simple  and  easy  exploration  of  the 
condition  of  the  uterus,  by  means  of  a  digital  examination, 
is  little  practiced.  Over  and  over  again  it  has  happened  in 
cases  brought  to  me  for  consultation  that  marked  antever- 
sion or  flexion  has  existed  and  remained  undetected  for 
this  reason  and  this  reason  alone:  the  condition  has  been 
unrecognized  simply  because  it  has  not  been  looked  for. 
The  too  exclusive  use  of  the  speculum  and  the  too  general 
concentration  of  attention  to  the  condition  of  the  os  uteri 
is  responsible  for  this  too  common  omission  of  the  digital 
examination. 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    29 1 

Thus  it  happens  that  these  affections  have  been  compara- 
tively neglected,  sometimes  because  they  have  not  been 
looked  for,  sometimes  because,  when  known  to  exist,  they 
have  been  misinterpreted.  We  may  now  proceed  to  the 
definition,  which  I  would  give  as  follows: 

Abnormal  atiteflexioti  or  version  exists  when  the  fundus  of  the 
uterus  can  be  felt  by  means  of  the  finger  introduced  as  far  as  the 
middle  of  the  proximal  phalanx^  the  patient  lying  on  the  side  and 
the  knees  drawn  up  in  a  favorable  position  for  such  exa?nina- 
tion.  For  the  application  of  this  definition  it  is  to  be  as- 
sumed that  there  is  no  tumor  or  considerable  enlargement 
of  the  uterus. 

The  above  definition  covers  by  far  the  majority  of 
cases,  but  not  all.  For  in  some  exceptional  instances  the 
uterus  lies  rather  high  and  yet  it  is  much  and  abnormally 
antefiexed. 

Neither  does  it  cover  those  cases  where  the  uterus  is  ex- 
cessively mobile  and  the  fundus  retreats  before  the  point 
of  the  finger,  for  in  such  cases  the  condition  might  be  over- 
looked. 

Neither  does  it  provide  certainly  for  the  recognition  of 
anteflexion  in  cases  where  the  uterus  is  excessively  soft,  for 
the  uterine  fundus  under  such  circumstances  may  not  be 
easily  felt  by  the  finger,  though  the  uterus  is  undoubtedly 
in  a  state  of  anteflexion. 

Neither  does  it  provide  for  recognition  of  cases  of  ante- 
flexion with  retroversion,  to  be  explained  further  on.  It 
will  be  found  on  practicing  the  investigation  above  de- 
scribed that  the  lower  border  of  the  triangular  ligament 
corresponds  to  the  joint  between  the  proximal  and  second 
phalanx  of  the  finger.  It  is  generally  easy  to  introduce  the 
finger  as  far  as  this  by  placing  the  patient  in  a  proper  posi- 
tion. I  consider  it  necessary  to  insist  on  the  observance  of 
this  latter  condition,  because  the  drawing  up  of  the  knees 
enables  the  observer  to  introduce  this  finger  nearly  an  inch 
farther  than  can  be  done  when  the  patient  is  in  any  other 
position. 

Theoretically  the  condition  of  the  bladder  might  be  sup- 
posed to  modify  the  results  of  the  examination.  But  prac- 
tically it  is  found  not  to  be  the  case,  for  if  abnormal  ante- 
flexion or  -version  be  present  the  fundus  of  the  uterus  is 
generally,  though  not  invariably,  always  within  reach  as 
above  described. 

To  come  within  the  above  definition  the  uterine  body 


^92  DISEASES   OF   WOMEN. 

must  have  become  materially  flexed  or  rotated  forward 
from  what  has  been  described  in  some  of  the  former  pages 
(see  page  164)  as  the  normal  position  of  the  uterus,  or  the 
uterus  must  have  as  a  whole  descended  much  lower  in  the 
pelvis  than  usual. 

It  will  be  found  that,  without  using  any  force,  it  is  gen- 
erally possible  easily  to  introduce  the  finger  to  the  extent 
of  three  inches,  and  when  the  fundus  is  easily  reached,  and 
its  outline  definable  within  this  distance  of  the  ostium 
vagina,  a  displacement  exists. 

The  question  as  to  the  normal  position  and  normal  mo- 
tion of  the  uterus  has  been  already  fully  discussed  at 
page  167. 

The  range  of  normal  anterior  motion  which  I  would  as- 
sign to  the  uterus  is  represented  in  the  accompanying  draw- 
ing (Fig.  71).  The  labia  majora  offer  a  projection  externally, 
and  a  portion  of  the  three  inches  constituting  the  available 
length  of  the  finger  is  occupied  in  traversing  the  vulva, 
generally  as  much  as  one  inch  (in  cases  of  obesity  more 
than  this),  so  that  only  two  inches  are  left  for  the  explora- 
tion of  the  vagina  proper.  It  is  possible  to  introduce  the 
finger  farther  than  this  by  exercising  some  degree  of  pres- 
sure, but  the  above  definition  applies  to  ordinary  explora- 
tion, without  exercise  of  undue  pressure.  (See  Fig.  8, 
showing  the  line  of  direction  of  a  digital  examination.) 

When  the  motion  of  the  uterus  does  not  exceed  what  has 
been  above  laid  down  as  the  normal  limit,  the  space  left 
between  the  uterine  fundus  and  the  pubic  symphysis  is  as 
nearly  as  possible  one  inch  and  a  half.  When  the  fundus 
encroaches  on  this  space,  therefore,  the  position  is  abnormal, 
unless  it  can  be  accounted  for  by  increased  size  of  the  whole 
organ.  This  latter  condition  would  obviously  have  to  be 
eliminated. 

Anterior  displacement  beyond  the  limit  mentioned  would 
bring  the  fundus  within  the  reach  of  the  finger,  introduced 
to  the  medium  degree,  as  above  described. 

There  are  cases  in  which  circumstances  prevent  the 
recognition  of  the  fundus  by  the  digital  examination,  some 
of  which  have  been  mentioned.  It  must  not,  therefore,  be 
concluded  absolutely,  because  the  fundus  cannot  be  detected 
by  the  touch  in  the  manner  directed,  that  no  anterior  dis- 
placement exists. 

It  is  to  be  remarked  that  the  directions  given  suppose  the 
patient  to  be  lying  on  the  side.     It  is  obvious  that  this  is 


ANTEFLEXION  AND   ANTEVERSION   OF   UTERUS.    293 

not  the  most  favorable  position  for  the  detection  of  a  slight 
anterior  displacement.  A  slight  anterior  displacement 
would   no  doubt  be  more  readily  detected  by  the  touch  in 

Fig.  71. 


the  upright  position.  But  tliis  consideration  is  in  favor  of 
the  definition  as  above  given,  for  the  patient  being  in  the 
lateral  position,  a  too  unfavorable  view  of  the  case  would 
not  be  so  likely  to  be  given  by  the  digital  examination.  In 
severe  cases  of  anteflexion  and  -version,  the  uterine  fundus 
is  very  readily  reached,  whether  the  patient  be  standing  or 
lying  on  the  side. 


294 


DISEASES   OF  WOMEN. 


ETIOLOGY. 

Predisposition. — There  can  be  no  doubt  that  there  is  what 
may  be  termed  a  special  predisposition  to  anteflexion  and 
-version  in  the  natural  slight  inclination  of  the  uterus  forward, 
and  in  the  fact  that  there  is  normally  a  very  slight  anterior 
curvature  of  the  uterine  canal.  Aided  by  its  own  natural 
firmness  and  rigidity,  and  supported  to  a  certain  extent  by 

Fig.  72.* 


the  moderately  distended  bladder,  the  position  and  shape 
of  the  uterus  are  in  a  state  of  health  preserved. 

The  relations  of  varying  conditions  of  the  bladder  to  the  nor- 
mal movements  of  the  uterus  have  been  considered  at  p.  173. 
Here  it  is  necessary,  however,  to  discuss  the  matter  further, 


*  The  above  drawing  is  Schultze's  representation  of  what  he  considers 
to  be  the  normal  outline  of  the  uterus  (nulliparous),  after  emptying  of  the 
bladder  and  rectum.     {Arch.  f.  Gyn.,  S.  142.) 


ANTEFLEXION  AND  ANTEVERSION  OF  UTERUS.   295 

as  it  lias  a  considerable  bearing  on  the  subject  now  under 
deliberation.  In  opposition  to  the  views  of  Schultze  *  I 
would  repeat  that  the  results  of  my  observations  do  not  sus- 
tain his  view  that  the  healthy  uterus  becomes  decidedly 
anteverted  and  slightly  flexed  when  the  bladder  is  empty. 
I  believe,  on  the  contrary,  that  the  space  in  the  pelvis  de- 
rived from  the  emptying  of  the  bladder  is  ordinarily  filled 
by  the  descent  of  the  intestines,  and  that  the  uterus  retains 
its  normal  (slightly  curved  forward)  shape  under  such  cir- 
cumstances. I  therefore  dispute  the  occurrence  of  what 
Schultze  terms  normal  anteflexion  and  -version,  at  all  events 
to  the  degree  described  by  him.  It  seems  probable  that  the 
case  or  cases  from  which  Schultze  took  his  drawings  of 
so-called  normal  anteflexion  would  only  truly  represent 
what  may  be  observed  in  cases  where  the  uterus  is  soft  and 
unduly  pliable,  but  then  I  should  deny  the  applicability 
of  the  term  "  normal  "  to  such  cases.  This  author,  whose 
able  memoirs  on  the  subject  may  be  consulted  with  advan- 
tage, appears  not  to  have  noticed  what  I  consider  to  be  a 
most  important  factor — namely,  the  softness  or  hardness  of 
the  uterus.  Assuredly  this  must  be  taken  into  account  in 
any  attempt  to  lay  down  a  law  as  to  the  definition  of  nor- 
mal and  abnormal  anteflexion. 

In  the  chapter  on  Etiology  of  Flexions  softness  of  the 
uterus  is  mentioned  as  a  powerfully  predisposing  condition. 
Here  these  observations  apply  with  peculiar  force.  A  very 
extensive  observation  has  convinced  me  that  it  is  a  factor 
of  the  extremes!  importance  in  bringing  about  anteflexion 
and  -version.  What  this  undue  softness  of  the  uterus 
means  has  been  discussed  in  a  former  chapter  (see  p.  98). 
This  want  of  tone,  want  of  rigidity  and  resistance,  on  the 
part  of  the  uterus,  places  it  at  the  mercy  of  external  influ- 
ences of  a  mechanically  disturbing  character.  A  year  or 
two  of  deficient  or  insufficient  feeding  suffices  to  produce 
decided  uterine  softness,  and  ordinary  exertions  may  then 
prove  too  much  for  the  stability  of  the  uterus.  The  ac- 
quired softness,  the  natural  inclination  of  the  uterus  for- 
ward, a  slight  exertion,  all  coming  together,  have  then  the 
result  of  bringing  about  mischief  of  a  decided  character. 
My  knowledge  of  softness  of  the  uterus  as  a  predisposition 
to  flexion  was  the  result  of  observation  of  cases  of  ante- 
flexion, and   I  have  been   familiar  with   this  softness   as  a 

*  Arch.  f.  Gyn.  8.  134. 


2(p  DISEASES   OF  WOMEN. 

frequent  condition  long  before  it  occurred  to  me  to  give  a 
satisfactory  explanation  of  it. 

Previous  pregnancy  is  responsible  for  innumerable  cases 
of  anterior  displacement.  It  acts  as  a  predisposition  by 
loosening  the  attachments  of  the  uterus,  leaving  it  in  a  soft 
bulky  condition;  and  under  these  circumstances  it  readily 
gives  way  when  the  patient  begins  to  move  about,  espe- 
cially if  there  be  added  the  debilitating  influences  of  a  defi- 
cient dietary  during  child-bed.  In  some  cases  of  abortion 
the  malady  begins  with  the  abortion  and  becomes  firmly 
established  when  the  uterus  is  allowed  to  set  and  become 
contracted  in  its  distorted  condition. 

Rupture  of  the  perineum  in  some  cases  favors  the  oc- 
currence of  anteflexion  and  -version.  I  have  seen  several 
cases  in  which  the  perineal  injury  seemed  to  have  been  the 
starting-point  of  the  displacement. 

Lastlv,  one  of  the  most  common  of  the  predisposing 
causes  of  anteflexion  and  -version  is  general  physical  weak- 
ness and  prostration.  Of  such  typical  instances  are  the 
weakness  produced  hy  typhoid  fever,  measles,  scarlet  fever, 
and  the  like.  I  have  seen  several  cases  where  the  malady 
began  unmistakably  on  getting  up  from  a  severe  attack  of 
fever,  and  some  of  the  most  severe  cases  of  anterior  dis- 
placement I  have  witnessed  have  been  of  this  kind.  It  is 
not,  however,  necessar)^  that  the  physical  exhaustion 
should  proceed  from  fever.  There  are  many  other  depress- 
ing influences  which  might  be  mentioned.  They  mostly 
act  by  reducing  the  tone  of  the  uterus,  softening  its  tissues, 
and  by  virtue  of  that  alteration,  predisposing  to  distortion 
of  the  organ. 

Special  or  Exciting  Causes  of  Anteflexion. — The  evidence  af- 
forded by  the  critical  investigation  of  cases  is  most  remark- 
able in  showing  the  very  great  influence  of  mechanical 
disturbing  agencies  in  the  production  of  anteflexion  or  -ver- 
sion. 

It  is  to  be  remembered  that  while  a  single  accident  or  se- 
vere strain  has  evidently  been  the  cause  in  a  number  of 
cases,  there  are  many  others  in  which  the  application  of 
the  cause  has  been  spread  over  a  considerable  time,  the 
uterus  having  been  displaced  by  the  continued — i.e.,  daily — 
operation  of  a  particular  exciting  cause.  Daily  severe  walks, 
daily  standing  for  many  hours  in  succession,  as  in  the  case 
of  shop-women,  severe  and  long-continued  standing  while 
nursing  a  sick  relative — these  are  instances  of  the  kind  al- 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    297 

luded  to.  Riding  on  horseback,  use  of  a  sewing  machine, 
are  other  causes  of  a  like  character — the  mischief  being 
done  not  necessarily  at  once,  but  by  slow  degrees. 

There  is  no  doubt  that  marriage  is  the  cause  of  anteflex- 
ion in  some  instances:  the  uterus  becomes  displaced  as  a 
result  of  the  act  of  intercourse  in  some  except'onal  cases. 

Some  few  cases  of  severe  anteflexion  and -version  arise 
from  exertion,  combined  with  a  chill  received  during  men- 
struation, which  I  attribute  to  the  occurrence  of  exudation 
or  thickening  around  the  uterus,  result  of  the  menstrual 
suppression,  whereby  the  uterus  becomes  more  or  less 
fixed  in  a  distorted  shape. 

The  relation  of  inflammatory  exudations,  effusions 
around  the  uterus,  parametritis,  etc.,  to  anteversion  and 
-flexion,  has  been  the  subject  of  a  paper  by  Schultze.* 
This  author  believes  that  a  principal  cause  of  what  he 
terms  "  pathological  anteflexion"  of  the  uterus  is  rigidity 
and  shortening  of  the  Douglas  folds  behind  the  uterus, 
which  rigidity  is  the  result  of  chronic  atrophic  parametri- 
tis affecting  the  connective  tissue  in  the  Douglas  pouch. 
Schultze  states  that  he  has  very  frequently  found  this  pos- 
terior fixation  along  with  anteflexion.  There  is  no  doubt 
that  undue  shortness  of  the  Douglas  folds  might  produce 
such  an  effect,  but  it  is  another  question  whether  the  occur- 
rence is  at  all  common.  Here,  again,  it  may  be  suggested 
that  in  the  cases  alluded  to  by  Schultze,  the  really  abnormal 
condition  may  have  been  a  very  soft  anteflexed  uterus,  and 
that  the  supposed  posterior  fixation  was  only  normal. 
Schroeder  and  Miiller  (of  Berne)  contest  the  accuracy  of 
these  views  of  Schultze.  I  have  in  some  few  instances  met 
with  a  condensed  resisting  condition  of  the  connective  tis- 
sue around  the  Douglas  pouch,  in  cases  of  anteflexion, 
where  there  had  been  pelvic  cellulitis.  Abnormal  shortening 
and  rigidity  of  the  Douglas  fold  is,  according  to  my  experi- 
ence, very  rare. 

It  is,  however,  not  uncommon  to  meet  with  what  may  be 
termed  parametric  exudation  and  hardening  around  the 
uterus,  so  far  as  can  be  explored  by  the  finger,  in  cases 
of  anteflexion  and  -version  of  a  chronic  character.  Such 
hardening  and  contraction  of  the  cellular  tissue  acts  as  a 
fixation  of  the  uterus,  and  indeed  offers  difficulty  in  elevat- 
ing and  straightening  it.     The  exudation  in  question  is  not, 

*  Archiv.  f.  Gyn.,  8.  i. 


29»  DISEASES   OF   WOMEN. 

however,  the  cause  of  the  flexion  and  displacement,  but 
precisely  the  opposite — it  is  the  result  of  it.  Pelvic  celluli- 
tis may  give  rise  to  a  localized  effusion  which  may  push  the 
uterus  quite  away  from  its  proper  position  to  one  side  or 
the  other,  or  backward  or  forward,  and  the  organ  may  be 
thus  pinned  down  as  it  were  by  such  exudation,  though  in- 
stances of  this  kind  are  not  common.  This  subject  will  be 
again  considered  in  describing  the  complications  of  ante- 
flexion and  -version. 


CHAPTER  XXII. 

Anteflexion  and  Anteversion  of  the  Uterus — 
{Continued^ 

Varieties. — i.  In  Degree  of  Flexion;  2.  Degree  of  Rotation  of  Uterus; 
3.  Degree  of  Descent  of  Uterus  as  a  Whole;  4.  Rigidity  of  Uterine 
Tissues — Various  Combinations  of  these  possible,  hence  Infinite  Dif- 
ferences of  Cases — Three  Principal  Degrees  of  Flexion — Some  Leading 
Types  Described — Various  Conditions  of  Cervix — Anteflexion  with 
Posterior  Rotation — Severe  Cases  in  which  the  Uterus  is  very  low 
down,  compressing  the  Rectum — \'ariations  in  Rigidity  of  Uterine  Tis- 
sue and  Connections — Clinical  Features  of  Different  Cases — Illustra- 
tive Cases  given — Degree  of  Congestion. 

Complications. — Congestion,  Accessions  of  Acute  Congestion — Disten- 
sion of  Cavity — Adhesions — Cystocele — Cystitis — Constipation. 

Symptoms. — Uterine  Dyskinesia — Illustrative  Facts  in  regard  to  this  ob- 
served in  Thirty-three  "  Fertile"  Women  and  in  Thirty  five  Single  Cases 
— Spontaneous  Pain — Tenderness  of  Uterus  to  Touch — Other  Abnor- 
mal Sensations —  Dysmenorrhoea,  Menorrhagia,  Leucorrhoea,  Amenorr- 
hoea — Sterility — Abortions — Dyspareunia — Reflex  Nervous  Symp- 
toms— Symptoms  referable  to  Bladder;  to  Rectum. 

Diagnosis. — Various  Difficulties — Method — Use  of  Sound — Precautions 
and  Difficulties  in  Introducing  it  in  Different  Cases. 

varieties. 

In  the  chapter  on  Retroflexion  and  -version  a  certain 
method  of  classification  has  been  adopted  which  may  with 
advantage  be  followed  so  far  as  the  circumstances  admit  in 
regard  to  anteflexion- and  -version.  Reasons  have  been 
there  (see  p.  252)  given  for  using  the  word  "  rotation"  in- 
stead of  "  version,"  and  the  same  reasons  render  it  conven- 
ient to  employ  this  term  in  describing  the  varieties  of  an- 
teflexion and  -version. 

Cases  may  be  classified  according  to 

I.  Degree  of  flexion — first,  second,  or  third,  as  the  case 
may  be;  also  the  variations  in  the  position  of  the  flexion. 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    299 

2.  Degree  of  rotation. 

3.  Degree  of  descent  of  uterus  as  a  whole. 

4.  Degree  of  resistance  offered  by  the  uterus  itself  to  un- 
bending or  replacement. 

5.  Presence  or  absence   of    (a)  congestion,    (^)  enlarge- 
ment. 

Seeing  that  in  practice  the  several  factors  above  detailed 
are  combined  in  different  ways  in  different  cases,  it  becomes 

Fig.  73. 


evident  that  infinite  varieties  may  be  observed.  It  is  a 
conclusion  to  which  all  who  study  the  subject  practically 
will  come,  that  hardly  two  cases  are  found  exactly  alike. 
The  appreciation  of  this  fact  is  necessary  for  success 
in  treatment,  every  case  having  peculiarities  of  its  own. 
The  above  classification  will  serve  to  indicate  the  points  to 
which  attention  must  be  directed  in  obtaining  a  definite 
and  broad  view  of  the  particular  case  before  us. 

Anteflexion  of  the  uterus,  according  to  Dr.  Emmet, 
affects  generally  the  cervix  of  the  uterus,  rarely  the  body. 
My  own  idea  on  the  subject  is  not  in  agreement  with  this 
view,  although  it  is  no  doubt  the  fact  that  many  cases  are 
observed  in  which  the  flexion  is  below  the  internal  os  uteri, 


300 


DISEASES   OF   WOMEN. 


What  may  be  termed  the  typical  varieties  of  anteflexion 
and  -version  will  now  be  described. 

Fig.  74. 


The  most  simple  case  is  that  in  which  the  uterus  is  flexed 
to  first  degree,  the  fundus  too  far  forward,  and  the  os  uteri 

Fig. 


a  little  nearer  the  sacrum  than  natural  (Fig.  73).    With  this 
is  frequently  associated  the  ftrst  degree  of  rotation  forward 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.   30I 

(the  latter  not  shown  in  accompanying  drawing);  a  second 
degree  of  anteflexion  is  shown  in  Fig.  74,  together  with  a 
slight  amount  of  rotation.  This  may  be  associated  with  a 
much  more  severe  degree  of  rotation  tlian  that  shown  in  the 
drawing. 

A  third  and  very  severe  form  of  anteflexion  is  shown  in 
Fig.  75,  together  with  some  degree  of  rotation. 

The  curve  offered  by  tlie  uterine  canal  in  cases  of  ante- 
flexion is,  according  to  my  experience,  a  gradual  one;  there 
is  no  sudden  alteration  in  the  direction  of  the  canal:  such 
a  sudden  change  in  direction  is  not  possible  under  ordinary 
circumstances,  the  bend  offers  degrees  as  above  stated — 

FiG.  76. 


first,  second,  and  third — but  the  bending  is  distributed  over 
three  quarters  of  an  inch  of  the  canal,  more  or  less,  in 
ordinary  cases.  The  Figs.  74  and  75  represent  this.  The 
actual  centre  of  the  bend  may  be  higher  or  lower  than  the 
internal  os  uteri. 

Rotation  is  found  in  very  different  degrees  in  different 
cases.  Thus  we  may  have  an  extreme  degree  of  rotation 
with  little  or  no  anteflexion.  Such  cases  have  been  termed 
anteversion  pure  and  simple.  They  are  by  no  means  com- 
mon; the  uterus  lies  almost  parallel  to  the  vaginal  canal; 
the  fundus  is  very  near  to  the  symphysis  pubis,  and  the 
posterior  wall  of  the  bladder  lies  in  close  coaptation  to  the 
base  of  the  bladder,  with  no  appreciable  interval.  Such  a 
case  15  shgwn  in  Fig.  76,     The  os  uteri  is  reached  by  the 


302 


DISEASES  OF  WOMEN. 


finger  with  great  difficulty,  as  it  lies  so  far  back  in  the  hol- 
low of  the  sacrum. 

As  a  rule  rotation  is  not  very  great  when  the  degree  of 
flexion  is  considerable,  and  in  this  respect  there  is  a  differ- 
ence between  cases  of  anteflexion   and    retroflexion  ;   the 

Fig.  77. 


4        \ 


bladder  offers  an  obstacle  to  very  considerable  anterior 
rotation.  Fig.  77  shows  three  degrees — (1)  first  degree  of 
anteflexion,  (2)  second  degree,  (3)  third  degree — of  flexion, 
together  with  the  more  usual  accompanying  degrees  of 
rotation. 

The  condition  of  the  vaginal  part  of  the  cervix  differs 


ANTEFLEXION  AND   ANTEVERSION   OF   UTERUS.    303 

very  much.  In  some  cases  it  is  nearly  straight  with  the  os 
directed  distinctly  backward;  but  in  many  instances  it  is 
bent  forward,  so  much  so  indeed  that  the  opening  of  the  os 
uteri  does  not  look  toward  the  vaginal  outlet  but  upward 
and  forward.  Thus  we  sometimes  meet  with  anteflexion  in 
the  third  degree  with  the  whole  uterine  canal  having  the 
form  of  a  parabolic  curve,  the  flexion  as  great  as  it  can  be. 
This  kind  of  case  is  more  often  met  with  in  young  women 
who  have  had  no  children;  the  cervix  has  a  conical  shape 
and  is  frequently  unduly  elongated.  This  considerable 
bending  of  the  vaginal  part  of  the  cervix  is,  I  believe,  due 

Fin.  78.* 


(as  Dr.  Emmet  remarks)  to  the  repeated  forcing  down  of 
the  uterus  against  the  vaginal  floor,  whereby  the  cervix  be- 
comes bent  and  turned  upward.  It  constitutes  a  condition 
very  troublesome  from  the  severity  of  the  symptoms,  and 
difficult  of  cure.  (See  Figs.  78,  79,  and  80.)  Some  observers 
regard  cases  similar  to  those  just  described  as  "congeni- 
tal."    Thus  Dr.  Roper f  says: 

I.  A  certain  class  of  cases  of  anteflexion  "are  congenital 
and  are  not  the  result  of  any  pathological  change  in  the 

*  Fig.  78  is  Dr.  Emmet's  drawing  of  a  severe  case  of  anteflexion,  the 
dark  line  A  B  C  D  showing  the  extent  of  incisions  made  in  his  operation 
for  the  cure  of  this  affection. 

f  "  Obst,  Trans.,"  vol,  xx.,  p.  304. 


304 


DISEASES   OF   WOMEN. 


uterine  texture,  but  are  malformations  of  the  whole  or  part 
of  the  organ." 

2.  "Acquired  flexions  generally  are  associated  with  some 
pathological  change  in  the  uterine  tissue,  whether  it  be  one 
of  hypertrophy,  atrophy,  or  degeneration." 

He  proceeds  to  explain  that  in  the  first  class  of  cases 
''there  is  an  antecurvature  of  the  uterus  running  from  the 
top  of  the  fundus  to  the  point  of  the  cervix,  extending  the 
whole  length  of  the  organ.  There  is  no  point  on  either  the 
cervix  or  body  at  which  a  flexion  exists  as  in  the  pathologi- 
cally flexed  organ"  {loc.  cit.,  p.  305). 

Fig.  79. 


The  context  shows  that  Dr.  Roper  only  admits  existence 
of  "flexion"  when  the  cervix  and  the  body  of  the  uterus  are 
separated  by  "an  intervening  portion  of  softened  tissue." 

And  when  he  finds  that  the  uterus  is  uniformly  solid  and 
rigid,  mere  curvature  does  not  for  him  constitute  flexion. 
But  it  is  to  be  remarked  that  the  consistence  of  the  uterine 
tissues  varies:  the  uterus  is  generally  in  a  soft  condition 
when  the  flexion  occurs,  but  it  may  and  frequently  does 
subsequently  become  firm  and  hard,  although  still  preserv- 
ing the  flexed  condition.  Dr.  Roper's  definition  of  flexion 
therefore  cannot  be  accepted,  and  the  cases  he  would  de- 
scribe as  cases  of  "congenital  antecurvature"  are,  in  my 
opinion,  for  the  most  part  cases  in  which  the  flexion  has 
arisen  in  the  manner  above  pointeci  out, 


ANTEFLEXION  AND   ANTEVERSION   OF   UTERUS.    305 

A  peculiar  variety  of  severe  flexion  of  the  cervix  is  shown 
in  Figs.  79  and  80;  here  the  uterus  is  anteflexed  in  about  the 
third  degree,  the  cervix  elongated  and  directed  forward  and 
a  little  upward.  It  may  be  termed  severe  anteflexion  of  the 
uterus  tvith posterior  rotation.  The  history  of  such  cases  is  as 
follows  :  Anteflexion  to  a  severe  degree  first  occurs,  and 
persists  for  a  considerable  time.  The  uterus  hardens  in  its 
anteflexed  condition,  but  subsequently  undergoes  posterior 
rotation,  by  which  it  acquires  the  position  and  shape  shown 
in  the  drawing.     It  is  not  easy  to   diagnosticate,  for  the 


Fig.  80. 


reason  that  there  appears  to  be  a  tumor  behind  the  cervix. 
Moreover,  the  sound  goes  in  at  first  in  the  direction  back- 
ward. The  absence  of  a  tumor  in  front  is  also  misleading; 
this  condition  was  first  described  by  me  in  the  1872  edition 
of  this  work.  I  have  met  with  at  least  a  dozen  such  cases 
in  practice. 

In  Figs.  81  and  82  is  shown  (life-size)  anteflexion  of  the 
uterus,  of  different  degrees  of  severity,  the  position  of  the 
adjacent  organs  being  also  depicted. 

Opportunities  are  rarely  afforded  for  obsQvving,post-»ior- 
tem,ihQ  condition  of  the  uterus  in  cases  of  anteflexion.    This 


3o6 


DISEASES    OF   WOMEN. 


being  so,  I  think   it  will  be  serviceable  to   reproduce  in  a 
slightly  abbreviated  form,  from  the  pages  of  Dr.  Ashwell's 
work,*  a  case  recorded  many  years  ago  by  that  most  care- 
ful and  unbiased  observer.  Dr.  Walter  Hayle  Walshe. 
The  case  was  observed  by  Dr.  Walshe  some  years  before 


Fig.  8i. 


in  the  wards  of  St.  Louis  Hospital  in  Paris.  He  gives  it 
as  almost  unique,  the  observation  of  the  symptoms  being 
followed  hs post-mortem  examination. 

Anteflexion  and  Anteversion  terminating  Fatally. — V.  E.,  aet. 
38.  Jan.  9. — Worked  as  charwoman  for  last  three  years; 
previously  portress  and  housemaid.     Had  six  children,  first 

*  "  Diseases  of  Women,"  1S44. 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.   307 

at  17,  last  at  age  of  23.  Menses  regular.  Subject  for  last 
five  5'-ears  to  pain  near  upper  border  of  sacrum  after  the 
least  fatigue.  Her  food  has  been  poor  in  quality:  she  has 
not  for  years  been  in  the  habit  of  eating  meat.  For  a  month 
before  Nov.  10  sacral  pain  increased;  only  slighth^  unwell 
on  two  preceding  periods.  On  Nov.  10,  while  engaged  in 
washing,  there  occurred  a  sudden  haemorrhage  with  large 

Fig  82. 


clots  from  vagina.  Felt  no  pain,  continued  her  work. 
Since  has  had  persistent  red  discharge,  which  for  a  month 
equalled  daily  the  quantity  lost  during  catamenia,  lately 
less.  Inguinal  pain  at  first  severe,  now  less;  for  last  fifteen 
days  occasional  pricking  pain  in  left  thigh;  has  lost  half 
her  former  flesh;  scarcely  ate  anything  during  first  month. 
Present  State. — .  .  .  Defaecation  unusually  difficult  for 
last  two  months  and  increasingly   so;  no  complaint  as  to 


3o8  DISEASES   OF   WOMEN. 

passing  urine.  Impossible  to  see  orifice  of  uterus  by  specu- 
lum. Examination  with  finger. — Neck  of  uterus  2^  inches 
from  vulva;  broad,  unusually  hard,  turned  backward. 
Anteriorly,  toward  pubis, a  tumor  is  felt  formed  by  the  body 
of  the  organ;  on  pushing  it  upward  depression  of  the  neck 
follows.  Pulse  76,  inodorous  vaginal  discharge,  equalling 
about  an  eighth  of  w-hat  is  lost  daily  during  menses. 

Feb.  12. — Discharge  of  late  increased  in  quantit}^  but 
patient  better  in  her  general  state.  To-day,  however,  a  new 
train  of  symptoms — great  swelling  and  tenderness  of  ab- 
domen, violent  pain  in  hypogastrium,  first  slightly  felt 
three  days  ago.  Bladder  not  distended;  frequent  vomiting 
of  greenish  matter,  on  increase.  No  relief  of  bowels  for 
four  days;  pulse  112,  regular,  very  small;  discharge  almost 
ceased;  decubitus  dorsal;  knees  raised,  features  contracted. 
Feb.  13. — Abdominal  tension  increased;  extreme  tympa- 
nitis; great  thirst;  pulse  126;  respiration  54.  Feb.  14. — 
Death. 

Fost-moriem  Fxaminaiion. — Intestines  adherent  by  false 
membrane;  clot  of  blood  size  of  tg^  in  Douglas  pouch, 
black  in  color:  "  to  account  for  it  there  appear  to  be  some 
vessels  open."  Here,  too,  are  several  loculi  with  pseudo- 
membranous walls  of  hardish  consistence  containing  putrid 
clots.  Sigmoid  flexure  adherent,  dull  red-colored  fluid 
beneath  adhesions,  and  surface  black. 

"Uterus  flexed  on  itself  at  an  obtuse  angle  at  the  union 
of  its  body  and  neck,  in  such  a  manner  that  the  fundus, 
concealed  by  the  bladder,  is  inclined  forward  and  down- 
ward, while  the  neck  is  inclined  backward  to  the  sacrum, 
the  posterior  surface  of  the  body  being  antero-superior. 
There  is  a  slight  lateral  obliquity  in  its  direction,  the  neck 
being  turned  somewhat  to  the  right  of  the  middle  line,  the 
fundus  toward  the  left  crural  arch.  The  body  of  the  organ 
as  well  as  the  neck  is  hypertrophous;  their  substance  is  of  a 
grayish  hue  and  hardened,  firm  and  resisting  throughout, 
except  at  the  union  of  those  parts  where  there  is  a  band  of 
the  organ  flattened  from  before  to  behind,  extremely  soft, 
flabby,  and  yielding,  and  corresponding  exactly  to  the 
angle  of  flexion.  Anterior  and  posterior  walls  of  the  body 
each  measure  precisely  an  inch  in  thickness;  neck  is  2I 
inches  wide,  its  orifice  gaping."  Right  ovary  enlarged, 
divided  into  cells  containing  a  puriform  fluid.  Left  ovary 
also  divided  into  loculi  with  citron-colored  serous  contents; 
a  small  reddish  clot  in  one  of  them. 


ANTEFLEXION  AND   ANTEV£RSI0N   OF   UTERUS.   309 

The  degree  of  descent  of  the  uterus  as  a  whole  is  an  im- 
portant factor  in  all  cases.  By  some  distinguished  gynaecol- 
ogists it  is  asserted  that  flexion  and  version  are  not  liable 
to  be  attended  with  symptoms  unless  the  uterus  is  very  low 

Fro.  8-!.* 


down  in  the  pelvis.     It  is  certainly  the  fact  that  the  lower 
the  uterus  the  greater  the  evil.     So  far,   but  no  farther,  I 

*  Fig.  83  represents  a  severe  chronic  case  of  anteflexion  of  probably 
fifteen  years'  duration,  in  a  patient  aged  36.  There  had  been  a  mis- 
carriage shortly  after  marriage,  and  several  attempts  had  been  made  to 
rectify  the  displacement  of  the  uterus.  The  organ  was  jammed  down- 
ward in  the  pelvis,  and  in  a  most  irritable  condition,  much  hypertrophied, 
and  a  chronic  neurosis  of  one  portion  of  the  cervical  canal  established. 
Severe  nausea,  constant  pain,  locomotive  inability,  were  the  chief  but  by 
no  means  the  only  symptoms. 


3  id  DISEASES   OF  WOMEN. 

would  express  my  general  assent  to  the  proposition.  It 
generally  happens  that  in  cases  of  anteflexion  the  descent 
of  the  uterus  as  a  whole  is  a  marked  feature.  The  uterus 
in  its  flexed  condition  becomes  rotated  and  at  the  same 
time  pushed  lower  and  lower  downward  toward  the  pelvic 
floor.  And  so  much  is  this  the  case  that  it  is  not  uncommon 
to  find  the  os  uteri  quite  close  to  the  tip  of  the  coccyx. 
Such  cases  are  most  troublesome.  A  typical  case  of  this 
kind  would  be  represented  as  follows:  The  uterus  in  the 
second  degree  of  anteflexion,  rotation  to  second  degree, 
the  OS  uteri  rather  far  back,  apparently  touching  the  coccyx, 
the  fundus  lying  very  near  to  the  pubic  symphysis.  Such 
a  case  is  not  uncommon  in  single  women  who,  after  many 
years'  continuous  suffering,  have  become  finally  incapaci- 
tated from  active  exertions  of  all  kinds  in  consequence  of  the 
pain  and  discomfort  produced  by  attempts  to  move  about 
in  tlie  ordinary  way  (see  Fig.  83  representing  such  a  case). 
A  very  troublesome  element  in  cases  where  the  uterus 
is  on  the  floor  of  the  pelvis  arises  from  the  pressure  on  the 
rectum,  and  the  most  obstinate  constipation  often  results. 
I  have  seen  one  extreme  case  in  which  the  uterine  cervix 
actually  inverted  the  rectum  and  protruded  at  the  anus. 

The  uterus  is  not  always,  however,  so  low  down  in  the 
pelvis.  It  may  be  acutely  flexed  and  yet  retain  its  normal 
position  so  far  as  elevation  in  the  pelvis  is  concerned;  the 
flexed  fundus  is  comparatively  high  up  and  is  reached  with 
less  ease  than  usual.  Schultze  seems  to  have  met  with 
such  a  condition  rather  frequently,  judging  from  liis  state- 
ments on  the  subject,  or  rather  from  tlie  drawing  he  gives 
to  illustrate  his  remarks.  But  it  is  to  be  remarked  that 
Schultze  believes  in  normal  anteflexion  to  an  extent  wliich 
I  deny.  The  result  of  the  difference  of  view  is  that  Schultze 
naturally  finds  few  cases  of  (pathological)  anteflexion  with 
the  fundus  low  down,  whereas  such  cases  are,  from  my 
point  of  view,  very  common. 

Another  very  important  distinction  to  be  made  is  as  re- 
gards the  degree  of  softness  or  hardness  of  the  uterus  and  the 
difficulty  or  facility  with  which  the  uterus  can  be  restored 
to  its  proper  position  and  shape  by  means  of  the  sound. 
This  applies  of  course  to  all  the  several  varieties  of  dis- 
placement above  described.  Here  is  an  opportunity  afford- 
ed for  what  may  be  termed  the  general,  as  opposed  to  the 
mechanical,  view  of  the  case  before  us.  It  is  necessary  to 
determine  how  far  the  uterus  is  fixed  and  hardened  in  its 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    3II 

disturbed  shape,  either  by  a  hardening  process  in  its  own 
tissues  or  by  external  fixation  due  to  hardening  of  the 
celhilar  tissue  and  connections  of  the  uterus. 

Thus  taking  a  case  of  the  second  degree  with  consider- 
able rotation,  we  ma}''  find  the  uterus  soft  and  spongy  and 
readily  straightened  and  elevated  to  its  proper  position;  or 
we  may  find  it  very  hard  and  firm,  and  the  attempt  to 
straighten  it  is  attended  with  difficulty;  or  we  may  find 
that  it  is  so  firmly  imbedded  and  jammed  downward  be- 

FlG    84. 


hind  the  s^'mphysis  that  its  elevation  is  almost  impossible 
at  the  moment  by  the  aid  of  tlie  sound.  In  long-standing 
cases  the  latter  difficulty  is  likely  to  be  encountered.  The 
annexed  drawings  illustrate  the  conditions  referred  to  in 
the  last  paragraph. 

In  Fig.  84  is  represented  a  case  of  severe  anteflexion  at 
age  of  19,  the  subject  of  which  was  a  patient  who  had  been 
incessantly  sick  for  ten  months,  the  displacement  caused 
by  a  jump  from  a  height  of  six  feet.  The  uterus  was  large, 
congested,  but  soft  and  spongy  in  texture. 

In  Fig.  85  is  represented  a  case  of  severe  anteflexion  at 


312 


DISEASES   OF  WOMEN. 


age  of  51,  the  subject  of  which  was  single  and  had  received 
an  injury  in  getting  over  a  stile  when  16  years  old.  She 
had  been  more  or  less  an  invalid  for  years.  Here  the  uterus 
was  very  large,  quite  fixed  in  its  low,  anteflexed  condition, 
and  it  was  evident  that  the  malady  had  been  in  existence 
for  many  years.     The  two  cases   above  related   are  quite 

Fig.  85. 


alike:  in  both  the  position  is  much  the  same,  but  in  the  one 
the  malady  was  recognized  sufficiently  early  to  be  quite 
and  rapidly  cured;  in  the  other  it  was  not  possible  to  alter 
the  position  of  the  uterus  and  the  time  had  passed  away 
for  attempting  it. 

All  gradations  are  met  with  both  in  regard  to  the  flexi- 
bilit}^  and  mobility  of  the  uterus.  As  a  rule,  when  the 
flexion  is  in  the  third  degree  the  uterus  is  not  easily 
straightened.     Sometimes   we  meet   with   cases  where  the 


ANTEFLEXION   AND   ANTEVERSION   OF    UTERUS.    3I3 

flexion  is  severe  but  the  general  mobility  considerable;  in 
such  cases  the  uterine  fundus  is  elevated  by  a  slight  pres- 
sure, but  the  flexion  remains,  and  although  the  rotation  is 
reduced,  the  flexion  continues.  This  fact  has  an  important 
application  in  the  treatment. 

The  sound  is  the  instrument  by  which  we  are  enabled  to 
judge  of  the  degree  of  rigidity  of  the  flexion,  and  of  the 
degree  to  which  it  resists  the  attempt  to  replace  and 
straighten  it. 

The  Degree  of  Congestion  or  Enlargement  of  the  Uterus. — 
Congestion  is  rarely  altogether  absent  in  cases  of  cinteflcxion 
and  -version.  But  it  is  very  much  more  severe  in  some 
cases  than  in  others.  The  fundus  uteri  is  much  larger  tlian 
usual,  due  to  long-continued  chronic  congestion  associated 
with  anteflexion  and  partly  causing  it,  and  being  partly 
caused  by  it.  First,  second,  or  third  degrees  of  anteflexion 
may  each  be  associated  with  slight,  severe,  or  very  intense 
congestion,  and  there  may  be  various  degrees  of  enlarge- 
ment. A  very  common  condition  in  women  who  have  had 
no  children  consists  in  combination  of  anteflexion  to  second 
degree,  rotation  to  second  degree,  and  enlargement  of  the 
uterus,  especially  the  fundus,  to  three  times  its  ordinary 
size.  Conditions  more  or  less  severe  than  this  may  be  en- 
countered. Congestive  enlargement  with  anteflexion  is 
by  no  means  limited  to  women  who  have  had  children. 

As  a  rule,  the  os  uteri  gives  evidence  of  considerable 
congestion;  this  is  more  decided  in  women  who  have  had 
children.  In  many  cases  of  pluriparae  the  os  presents 
considerable  swelling,  and  congestion  especially  of  the 
anterior  lip.  In  chronic  anteflexion  affecting  pluriparae  the 
OS  uteri  presents  very  great  hypertrophy,  the  result  of  long- 
continued  congestion. 

In  not  a  few  cases,  also,  in  pluriparae  there  is  eversion  of 
theliningof  the  cervix,and  the  generally  depressed  condition 
of  the  uterus  gives  rise  in  such  cases  to  great  friction  of 
the  OS  against  the  vaginal  floor.  The  congestion  and 
irritation  observed  at  the  os  uteri  in  many  such  cases  has 
long  obscured  their  true  nature.  These  appearances  usually 
result  from  the  general  congestion  of  the  uterus  itself, pro- 
duced in  most  cases  by  the  anteflexion.  In  some  instances 
they  result  from  lacerations  of  the  cervix  uteri  during 
labor. 

Complications. — Congestion  of  the  uterus  is  the  most  com- 
mon of  the  complications  of  anteflexion,   as  has  already 


314  DISEASES   OF  WOMEN. 

been  stated.  The  congestion  may  be  very  acute,  giving  rise 
to  exceeding  sensitiveness  to  toucli,  to  severe  spasmodic 
pains,  to  great  swelling  of  the  uterus  as  a  whole,  to  a  sort 
of  strangulation  of  the  whole  organ.  This  may  pass  into  a 
sub-acute  and  then  into  a  chronic  stage.  In  the  chronic 
stage  frequent  accession  of  acuteness  may  occur.  In  the 
end,  the  uterus  acquires  great  size  and  permanent  hyper- 
trophy. Distension  of  the  uterine  cavity  is  rather  common 
as  a  complication  of  anteflexion;  the  cavity  is  often  of  con- 
siderable size,  forming  a  large  pouch,  in  which  blood  col- 
lects during  menstruation,  and  puriform  fluid  at  other 
times. 

Adhesions  of  a  peritoneal  character  do  not  appear  to  be 
common,  but  fixation  is  not  very  rare.  It  is  especially  ob- 
served in  long-standing  anteflexions  where  the  uterus  is 
very  low  down  in  the  pelvis  and  has  carried  with  it  the 
floor  of  the  bladder.  Such  a  condition,  when  of  long 
standing,  renders  restitution  of  the  uterus  to  its  proper 
shape  and  position  a  work  of  great  difficulty.  It  may  be 
easily  confounded  (and  indeed  may  be  associated)  with 
hardness  or  rigidity  of  the  uterus  itself. 

Cystocele  is  a  possible  complication  of  severe  anteflexion, 
the  uterine  fundus  forcing  the  bladder  downward  and 
partly  outward.  I  have  seen  such  a  case  in  a  patient  who 
had  never  borne  a  child. 

In  pluriparae,cystocele  generally  occurs  in  connection  with 
ruptured  perineum;  the  anteflexion  and  the  cystocele  are 
then  traceable  to  defective  perineal  support. 

Cystitis  is,  I  believe,  more  frequently  the  result  of  ante- 
flexion of  the  uterus  than  is  supposed.  It  is  very  common 
to  meet  with  extreme  irritability  of  the  bladder  in  cases  of 
anteflexion  owing  to  the  mechanical  pressure  of  the  fundus 
on  the  bladder  and  interference  with  its  retentive  power, 
but  I  have  seen  some  few  cases  of  very  severe  cystitis  cer- 
tainly due  to  anteflexion,  some  of  which  have  been  at  once 
cured  on  relief  of  the  uterine  displacement. 

Chronic  constipation  is  exceedingly  common,  due  to 
mechanical  pressure  on  the  rectum. 

Symptoms. — It  has  been  stated  in  describing  the  symptoms 
observed  in  flexions  of  the  uterus,  that  one  of  the  most 
common  is  pain  during  locomotion.  This  symptom,  uterine 
dyskinesia,  is  not  peculiar  to  any  special  form  of  uterine 
flexion,  but  it  is  a  very  noticeable  symptom  in  anteflexion 
and  -version.     Peculiar  interest  attaches  to  this  symptomj 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERL'S.    315 

because  its  intensity  in  anteflexion  is  a  test  of  tlie  degree  of 
importance. 

It  has  been  my  practice  always  to  inquire  of  patients 
wliat  it  is  they  complain  of,  and  the  following  is  a  part  of 
the  reply  given  in  the  cases  referred  to.  There  are  two 
series  of  cases,  and  they  are  taken  from  my  case-book,  the 
words  given  being  generally  those  actually  used  by  patients 
in  reply  to  the  interrogation  above  mentioned. 

Cases  of  Anteflexion  or -version  of  the  Uterus — Patients  all  belonging  to  tkt 
"  Fertile  "  Series. 


1.  Constant    feeling    of     bearing- 

down  in  walking. 

2.  Since  a  strain,  two  months  ago, 

not  able  to  walk. 

3.  Pain  on  rising  from  bed  in  morn- 

ing. 

4.  Locomotion  difficult. 

5.  Incapable  of  locomotion. 

6.  Walking   power  gone  last  four 

months. 

7.  Locomotion  very    difficult    and 

painful. 

8.  Locomotion  painful, 
g.   Walking  power  small. 

10.  Almost  incessant  unpleasant 
sensations,  a  sort  of  aching 
only  going  away  when  in  bed. 

ir.   Locomotion  difficult. 

12.  VValking  power  small. 

13.  Strained   feeling;    cannot  stand 

any  time. 

14.  Unable    to  walk  from    pain  in 

side. 

15.  Cannot  walk. 


16.  Walking  painful. 

17.  Feels  sitting  much. 

18.  Complete  inability  for  locomo- 

tion. 

19.  Inability  to  walk. 

20.  Pain  in  walking. 

21.  Cannot  walk  far  without  pain. 

22.  Feels  dragged. 

23.  Pain  in  walking. 

24.  Walks  badly. 

25.  Pain  right  side  on  motion. 

26.  Bearing-down     in    walking    or 

standing. 

27.  Standing  difficult  from   pain  in 

hypogastric  region. 

28.  One  day,  six  weeks  ago,  found 

could  only  take  short  steps 

29.  Continuous  pain  right  side,  since 

a  week's  e.xertion  in  shopping. 

30.  Cannot  walk. 

31.  Discomfort  after  exertion. 

32.  Pain  and  discomfort  following 

exertion. 

33.  Exertion  painful. 


Cases  of  Anteflexion  or  -version  of  the  Uterus — Patients  either  Single  or,  if 
Alarried,  Sterile. 


1.  Walking  always  produces faint- 

ness. 

2.  Never  could  walk  much. 

3.  Can  walk  only  short  distance. 

4.  Can   only   walk  very  short  dis- 

tance without  pain. 

5.  Tires  readily. 

6.  Locomotion  not  practiced. 

7.  Walking  power  left  her  nineteen 

years  ago. 

8.  I rtcapable  of  locomotion. 


9.   Cannot  sit  upright  from  pain  in 
back. 

10.  Pain  on  locomotion. 

11.  Locomotion    painful   after   five 

minutes. 

12.  Tired  easily. 

13.  Cannot  walk  well. 

14.  Walking  produces  pain. 

15.  Incapable  of  locomotion. 

16.  Standing,  ever  so    little,  insup« 

portable. 


3l6  DISEASES    OF   WOMEN. 


17.   Cannot  walk. 

iS.   Walks  badly. 

19  Dragging  pain  in  back,  especial- 
ly walking  or  standing;  bear- 
ing down. 

20.  Peculiar    sensation    in    groins, 

and  a  sick  feeling  on    walk- 
ing. 

21.  Extreme    incapacity  for    move- 

ment. 

22.  Incapacity  for  locomotion. 

23.  Pain  and  inability  to  walk. 

24.  Never  could  walk  well. 

25.  Cannot  walk  freely  or  sit  easi- 

ly. 


26.  Pain  in  side  increased  by  exer- 

tion. 

27.  Very  little  walking  power. 

2S.    Great  difficulty  in  locomotion. 
2g.   Severe  pain  right  groin,  worse 
after  exertion. 

30.  Pain  in  back  increased  by  walk- 

ing. 

31.  Walking  fatigues  much. 

32.  Cannot  walk  well. 

33.  Walking  power  little,  formerly 

good. 

34.  After  walking  feels  tumbling  to 

pieces. 

35.  Cannot  walk  much. 


The  above  are  extracts  from  reports  of  cases  observed 
during  three  years  in  private  practice,  and  it  does  not  by 
an\'  means  include  all  the  cases  of  anteflexion  in  which  the 
symptom  in  question  occurred.  In  those  cases  above  re- 
ferred to  it  was  so  noticeable  a  symptom  that  the  patient 
generally  spontaneously  mentioned  it  on  being  asked  "  what 
she  complained  of." 

In  point  of  fact  uterine  dyskinesia  is  the  principal  symp- 
tom in  a  very  large  number  of  cases  of  anteflexion  and 
version. 

Certain  positions  of  the  body,  even  in  a  state  of  repose, 
give  rise  to  great  pain  and  irritation  in  many  cases  of  ante- 
flexion. Thus,  the  sitting  posture  gives  great  discomfort 
in  many  cases,  especially  bending  forward,  as  in  the  act  of 
writing,  sitting  on  a  low  chair,  and  bending  forward  par- 
ticularly. Riding  in  a  ca-rriage  in  the  ordinary  position 
often  produces  the  greatest  discomfort;  the  combination  of 
sitting  and  being  jolted  b}'  the  motion  of  the  carriage  is 
often  very  distressmg  in  its  effects.  Anything  calling  into 
action  the  abdominal  muscles  may  give  great  pain  even 
when  the  patient  is  otherwise  quiet;  even  putting  up  the 
arms  to  dress  the  hair  gives  great  pain  in  some  cases. 

Spontaneous  pain  is  very  frequently  observed.  This  pain 
generally  in  the  sacral  region,  but  very  frequently  also  it  is 
felt  in  one  of  the  groins.  In  a  few  cases  it  is  very  severe 
and  constant,  but  as  a  rule  when  the  patient  is  at  rest  there 
is  little  spontaneous  pain. 

Tenderness  of  the  Uterus  to  the  Touch. — This  symptom  is 
severe  in  some  cases.  In  fact  the  anteflexed  uterus  is  some- 
times so  sensitive  to  the  toucli  that  the  greatest  difficulty 
is  experienced  in  making  a  simple  examination,      It   is  not, 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    317 

however,  so  common  to  find  extreme  sensitiveness  in  ante- 
flexion as  in  retroflexion.  The  tenderness  affects  the  os 
uteri.  In  some  cases  the  sensitiveness  is  not  felt  at  the  os 
uteri  so  much  as  within  tlie  canal.  The  internal  os  uteri  is 
not  seldom  the  seat  of  a  very  extreme  sensitiveness,  the 
patient  screaming  out  when  the  extremity  of  the  sound 
reaches  the  point  in  question.  There  is  generally  acute 
congestion  of  the  uterus  when  general  sensitiveness  is 
present,  and  when  the  uterine  canal  is  so  sensitive  the 
flexion  is  an  acute  one  and  is  generally  of  long  standing. 
In  such  cases  a  neurosis  has  been  established  at  a  certain 
situation,  and  the  spot  is  usually  quite  definable,  other  parts 
of  the  uterus  being  comparatively  non-sensitive. 

In  a  few  cases  we  meet  with  chronic  congestion  and  en- 
largement, together  with  anteflexion  and  severe  sensitive- 
ness which  remains  so  long  as  the  flexion  and  congestion 
persist,  but  disappears  for  a  time  under  treatment.  This 
recurs  from  time  to  time  unless  means  are  taken  to  prevent 
the  descent  of  the  fundus  forward.  When  tenderness  to 
the  touch  is  felt  just  above  the  groin  on  one  side,  the  idea 
naturally  suggests  itself  that  it  is  due  to  some  quasi-inflam- 
matory condition,  and  it  has  frequently  been  assumed  that 
it  arises  from  ovaritis.  I  have  seen  many  such  cases  in 
which  no  tenderness  of  tlie  ovary  could  be  detected  by  care- 
ful examination  from  within,  but  where  the  uterus  was  found 
to  be  anteflexed  and  proved  to  be  the  source  of  the  pain. 

Various  abnormal  sensations  are  experienced  by  patients 
suffering  from  anteflexion  or  -version  not  included  in  the 
foregoing  account.  A  sensation  of  weight  in  the  hj'pogas- 
trium  is  common,  especially  in  patients  who  have  had  chil- 
dren; a  bearing-down  sensation  is  not  uncommon.  A  sen- 
sation of  movement,  a  sort  of  rolling-about  feeling,  within 
is  occasionally  described.  A  feeling  of  sickness  or  nausea 
is  very  common:  this  S5'mptom  is  generally  brought  on  by 
exertion, or  by  sitting  in  a  constrained  or  upright  position. 

Dysiiienorrhxa  is  a  very  common  symptom.  It  exists  in 
all  degrees  of  severity.  It  is  very  rare  indeed  to  find  a 
case  of  marked  anteflexion  in  which  menstruation  is  nor- 
mal and  unattended  with  pain.  Taking  cases  of  dysmenor- 
rlioea  in  bulk,  it  will  be  found  that  the  most  common  cause 
is  anteflexion  or  -version  of  the  uterus.  The  uterine  canal 
is  narrowed  by  the  flexion,  the  outlet  for  the  uterine  secre- 
tion is  restricted  and  pain  ensues. 

Menorrhagia  is  not  uncommon   in    cases  of  anteflexion. 


318 


DISEASES   OF  WOMEN. 


This  symptom  is  sometimes  observed  in  a  very  marked 
degree  in  young  women  during  the  first  two  or  three  years 
after  commencement  of  the  process.  I  have  seen  cases  of 
this  latter  kind  wliere  the  loss  was  almost  continuous  for 
a  month  together,  and  where  the  anteflexed  condition  of  the 
uterus  was  found  to  be  the  cause.  It  is  true  such  extreme 
cases  are  not  common.  Menorrhagia  is  more  common  in 
cases  where  the  uterine  flexion  has  existed  some  time,  and 
the  uterus  has  become  enlarged,  its  interior  greatly  ex- 
panded, and  the  fundus  forms  a  pouch  hanging  forward 

Fig.  86. 


in  an  acutely  anteflexed  state.  (See  Fig.  86.)  Blood  col- 
lects in  its  interior  and  escapes  in  large  gushes  from  time 
to  time. 

Leucorrhoea  is  very  common.  The  discharge  may  be  due 
to  the  congestion  and  irritation  of  the  os  and  cervical  canal, 
but  it  is  not  seldom  an  intra-uterine  leucorrhoea,  due  to  re- 
tention of  secretion  within  the  uterus,  to  an  irritated,  vas- 
cular condition  of  the  uterine  interior  (so-called  "  en- 
dometritis"), concomitant  with  and  arising  out  of  cervical 
obstruction  and  flexion.  The  leucorrhoea  in  the  latter  case 
is  often  observed  in  form  of  gushes  of  sanious  fluid.  It 
may  even  become  offensive  to  the  smell.  I  have  seen  a  case 
in  a  single  patient  who  had  for  some  time  been  subject  to 
an  offensive  leucorrhoea,  due  to  a  flexion  of  the  uterus,  and 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    319 

which  entirely  disappeared  when  the  flexion  was  cured. 
Obstinate  long-standing  cases  of  leucorrhoea  will  sometimes 
be  traced  to  an  unsuspected  anteflexion. 

Amenorrhcea. — This  symptom  is  occasionally  met  with,  the 
orocess  of  menstruation  having  become  entirely  and  pre- 
maturely arrested  by  the  anteflexion.  In  other  cases  it  is 
observed  to  be  very  scanty. 

Sterility. — Anteflexion  is  one  of  the  commonest  causes  of 
sterility.  Fecundation  is  prevented  by  mechanical  obstruc- 
tion to  the  passage  of  the  zoosperms,  or  by  the  altered  char- 
acter of  the  uterine  secretions. 

Sterility  is  primary  in  many  cases,  in  others  it  is  second- 
ary; that  is  to  say,  the  patient,  having  had  one  or  more 
children,  becomes  affected  with  severe  anteflexion,  and 
thereafter,  or  until  cured  of  the  anteflexion,  remains  ster- 
ile. 

Abortions. — Anteflexion  is  responsible  for  a  great  number 
of  abortions.  The  patient  has  a  slight  anteflexion;  she  be- 
comes pregnant;  the  uterus  does  not  expand  properly  ow- 
ing to  the  flexion;  abortion  results.  Or  the  uterus  is  weak, 
and  an  accident  or  fall  produces  anteversion,  followed  by 
an  abortion.  But  the  former  is  the  more  common  order  of 
events. 

Dyspareuiiia. — Pain  in  intercourse  is  a  symptom  some- 
times existing  to  a  great  degree  of  severity.  Physical  in- 
jury is  no  doubt  often  inflicted  by  excesses  in  regard  to  inter- 
course, and  the  uterus  is  in  some  cases  actually  displaced 
in  consequence.  But  dyspareunia  may  exist  when  there  has 
been  no  such  history  of  excess  in  this  direction. 

Reflex  Nervous  Symptoms. — In  order  to  avoid  unnecessary 
repetition,  these  symptoms  will  be  considered  in  a  separate 
chapter.  Reflex  nervous  symptoms  are  exceedingly  fre- 
quent in  cases  of  anteflexion  or  -version,  especially  sickness 
and  nausea;  but  as  these  symptoms  are  not  peculiar  to  this 
special  variety  of  uterine  flexion  it  w'ill  be  best  to  discuss 
them  from  a  more  general  point  of  view.  (See  chapters  on 
Association  of  Pregnancy  with  Flexions,  and  on  the  Vom- 
iting of  Pregnancy.) 

Symptoms  relating  to  the  Bladder. — Frequency  of  micturition 
is  a  very  common  symptom  in  cases  of  anteflexion  or  -ver- 
sion. It  is  sometimes  the  principal  symptom.  In  a  few 
cases  it  is  so  productive  of  inconvenience  and  distress  that 
the  patient  thinks  of  nothing  else.  The  necessity  for  evac- 
uating the  contents  of  the  bladder  may  be  as  often  as  every 


320  DISEASES   OF  WOMEN. 

hour,  or  even  less.  It  is  generally  limited  to  the  day,  which 
means  that  when  the  patient  is  in  the  horizontal  position  it 
is  not  so  liable  to  occur.  It  is  generally  worse  at  the  men- 
strual periods,  but  I  have  known  cases  where  it  was  always 
better  at  those  times.  The  symptoms  depend  for  the  most 
part  on  the  pressure  of  the  body  of  the  uterus  on  the  blad- 
der and  interference  with  its  due  expansion.  But  there  is 
evidence  of  cystitis  in  some  cases.  When  the  anteflexion 
has  existed  for  some  time,  the  bladder  either  becomes  more 
tolerant  of  pressure  or  expands  in  a  new  direction,  and  the 
irritability  may  cease. 

Pain  after  micturition  is  a  condition  which  is  met  with  in 
some  rare  cases  of  anteflexion.  A  curious  case  I  have  in  my 
recollection  in  which  a  young  lady  had  been  affected  for 
three  years  with  this  symptom,  which  completeh'  destroyed 
her  comfort.  It  appeared  to  depend  on  the  contact  of  the 
opposite  sides  of  the  bladder,  due  to  a  severe  anteflexion, 
and  it  disappeared  on  treatment  of  the  latter  condition. 

Symptoms  i-eferable  to  the  Rectum. —  Constipation  of  a  very 
obstinate  character  is  observed  in  many  cases  of  anteflexion 
or  -version.  It  appears  to  be  a  mechanical  effect  of  the  al- 
tered position  of  the  uterus.  In  some  cases  severe  straining 
efforts  are  quite  ineffectual:  the  uterus  being  forced  down 
on  the  floor  of  the  pelvis  the  rectum  is  effectually  blocked. 
It  is  perhaps  not  at  first*  easy  to  say  why  this  should  occur 
in  some  cases  to  such  a  marked  extent  and  not  at  all  in 
others.  The  explanation  may  be  that  when  obstruction  oc- 
curs the  cervix  uteri  happens  to  be  forced  down  in  the  cen- 
tre of  the  rectum,  while  it  avoids  the  exact  centre  in  others. 
I  have  seen  cases  in  which  all  kinds  of  medicine  had  been 
tried  unavailingly,  and  in  which  restoration  of  the  uterus 
to  its  proper  position  was  effectual  in  relieving  the  consti- 
pation. 

A  case,  already  mentioned,  once  came  under  my  notice 
where  the  cervix  uteri  was  actually  forced  by  expulsive 
efforts  into  the  rectum,  everting  it  and,  projecting  at  the 
rectal  aperture,  effectually  blocked  the  passage,  but  I  have 
only  seen  one  such  case. 

DIAGNOSIS. 

On  the  subject  of  the   diagnosis  much  has  already  been 

said  in  speakingof  the  definition  of  anteflexion  and  -version. 

The  diagnosis  is  easily  arrived  at  in   most  cases,  the  pa- 


ANTEFLEXION  AND  ANTEVERSlON  OF  UTERUS.  32 1 

tient  being  properly  placed  and  the  finger  introduced  in 
the  manner  described  in  a  former  cliapter  (see  page  27). 

Tho.  digital  examination  gives  the  most  reliable  informa- 
tion, and  unless  it  is  thoroughly  done  no  satisfactory  no- 
tion of  the  case  is  obtained. 

In  this  manner  the  roof  of  the  vagina  should  be  carefully 
explored  and  the  position  of  the  body  of  the  uterus  ascer- 
tained— its  size,  width,  distance  from  the  pubic  bones,  and 
the  elevation  of  the  uterus  as  a  whole  in  the  pelvis. 

If  the  finger  can  be  pushed  upward  in  tliis  position  with- 
out encountering  the  resistance  of  the  body  of  the  uterus, 
as  a  general  rule  it  may  be  taken  that  the  uterus  is  not  an- 
teflexed  or  anteverted.  This  is  a  rule  to  which  there  are 
exceptions,  as  pointed  out  at  page  291.  As  to  recognizing 
the  body  of  the  uterus  by  the  touch,  it  is  a  matter  of  skill, 
requiring  practice  to  obtain  accuracy  and  certainty.  Tlie 
greatest  real  difficulty  will  be  found  in  cases  where  the  roof 
of  the  vagina  presents  a  hardened  resisting  condition,  which 
may  turn  out  to  be  either  anteversion  and  -flexion ///^j' some 
exudation  hardening,  or  exudation  hardening  alone.  An- 
other cause  of  difficulty  is  the  retreating  or  rotation  back- 
ward of  the  fundus,  which  sometimes  happens  by  the  mere 
pressure  of  the  exploring  finger.  The  tumor  or  resisting 
mass  felt  through  the  vaginal  roof  is  generally  recognizable 
as  the  body  of  the  uterus  by  its  continuity  with  the  cervix, 
by  its  shape,  size,  etc.  The  uterine  body  is  often  a  little  to 
one  side  of  the  middle  line  and  not  exactly  median  in  posi- 
tion. In  some  cases  the  lateral  deviation  is  yet  more  de- 
cided, although  it  does  not  amount  to  lateriflcxion.  These 
cases  give  great  trouble  in  regard  to  treatment  unless  this 
lateral  tendency  is  duly  recognized  and  adequately  guarded 
against. 

When  the  flexion  is  high  up  and  the  uterus  not  much  ro- 
tated forward,  the  ordinary  digital  exploration  may  fail  to 
detect  it.  These  are  quite  exceptional  cases,  however. 
When  the  uterus  is  very  soft  and  pliable,  the  exploring  fin- 
ger, unless  carefully  educated,  may  fail  to  recognize  its 
presence  through  the  vaginal  roof. 

The  double  touch  is  very  useful  in  difficult  cases. 

A  vaginal  examination  cannot  be  always  made.  In  young 
single  women  this  examination  would  of  course  be  deferred 
as  long  as  possible,  or,  at  all  events,  not  undertaken  lightly. 
Information  can  often  be  procured  by  digital  examination 
of  the  rectum,  and  an  anaesthetic  could  be  employed  to  ren 


322  DISEASES   OF   WOMEN. 

der  the  examination  more  easy.  As  regards  the  necessity 
of  a  local  exploration  it  is  impossible  to  lay  down  a  univer- 
sal law.  Incapacity,  of  some  months'  standing,  for  ordi- 
nary exertion  should  induce  taking  the  case  seriously  into 
consideration,  and  in  the  first  place  a  rectal  examination 
could  be  made.  If  the  existence  of  a  marked  displacement 
were  thus  made  out,  the  course  would  be  comparatively 
clear;  and  if  none  were  detected  so  much  the  better  for  the 
patient. 

The  use  of  the  soicnd  is  very  necessary  in  many  cases  to 
clear  up  diagnostic  difficulties.  The  sound  should  never 
be  ustd  first :  a  digital  examination  should  always  precede 
it,  otherwise  the  body  of  the  uterus  may  be  pushed  by  it 
into  a  different  position  and  the  observer  may  be  misled. 
Wiien  the  uterus  is  unduly  soft  this  latter  event  is  very 
likely  to  occur;  and  I  know  of  cases  in  which  marked 
anteflexion  has  been  entirely  overlooked,  apparently  be- 
cause it  was  found  that  the  sound  could  be  passed  without 
mucli  difficulty.  The  fact  is,  that  in  some  cases  the  sound 
unbends  the  uterus  in  the  act  of  introduction. 

Knowing  that  there  is  a  tumor  anteriorh'-,  anteflexion 
would  be  suspected,  and  the  point  of  the  sound  kept  in- 
clined forward  as  it  is  being  introduced.  The  introduction 
may  be  extremely  difficult — generally  is,  in  fact,  when  the 
uterus  has  been  some  time  affected. 

I  prefer  to  use  the  sound  almost  straight  (see  represen- 
tation of  shape  of  sound  at  page  73).  In  cases  of  ante- 
flexion the  cervix  uteri  is  generally  rather  far  back,  often 
very  much  so — so  that  the  first  difficulty  is  to  get  the  point 
of  the  sound  in  the  os  uteri  at  all.  Having  inserted  it 
about  half  an  inch,  the  next  procedure  is  to  incline  the 
point  of  the  sound  upward  and  forward,  and  at  the  same  time 
to  draw  the  uterus  as  a  whole  a  little  toward  the  symphysis 
by  means  of  the  sound.  The  result  of  this  usually  is  that 
the  advance  of  the  sound  through  the  cervical  canal  is 
facilitated:  the  uterus  really  begins  to  be  straightened. 
Then,  by  gradually  depressing  the  handle  more  and  more 
toward  the  rectum  the  sound  can  be  introduced  to  its  full 
extent.  The  process  should  be  a  slow  one,  and  no  force 
used.  It  may  be  taken  for  granted  that  if  a  difficulty  is 
met  with,  it  is  due  to  the  point  of  the  sound  not  being  made 
to  assume  a  proper  direction.  There  are  really  few  cases 
in  which  the  passage  is  so  much  narrowed  that  the  entry 
of  the  ordinary  sound  is  impossible.     It  is  almost  impos- 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    323 

sible  to  introduce  a  nearly  straight  sound  into  a  uterus  in 
the  third  degree  of  anteflexion  and  forward  rotation,  unless 
the  above  directions  are  carried  out.  When  the  sound  is 
completely  in  the  uterus  tiie  position  of  the  fundus  is  cer- 
tainly indicated;  but,  as  already  remarked,  the  flexion  may 
have  been  got  rid  of  in  the  mere  act  of  introducing  the 
sound.  The  sound  is  very  valuable  in  diagnosing  absence 
of  tumors  in  the  anterior  wall.  Sometimes  appearances  are 
very  deceptive  in  this  respect:  the  use  of  the  sound  reveals 
not  uncommonly  that  what  was  supposed  to  be  a  tumor  is 
really  nothing  more  than  the  third  degree  of  anteflexion. 

The  ordinary  sound  cannot  always  be  introduced,  a 
smaller  one  is  sometimes  required. 

In  cases  of  anteflexion  \\\ih  posterior  rotation  the  passage 
of  the  sound  is  confusing  at  first,  for  the  sound  appears  to 
pass  backward  until  one  inch  and  a  half  perhaps  has  been 
inserted,  and  this  may  give  the  notion  of  existence  of  retro- 
flexion, but  on  afterward  turning  the  point  sharply  upward 
and  forward  the  true  nature  of  the  case  is  revealed. 

The  condition  of  the  os  uteri  gives  some  information  in 
many  cases.  In  pluriparae  the  os  is  a  little  open,  or  may  be 
much  open,  and  the  anterior  lip  is  often  very  much  swollen 
and  everted  (the  contrary  to  that  which  happens  in  retro- 
flexion), and  the  shape  of  the  os  is  crescentic,  the  concavity 
of  the  crescent  upward. 

The  position  of  the  cervix  varies  according  to  the  nature 
of  the  flexion.  The  cervix  is  generally  far  back — it  may  be 
so  far  back  as  to  be  reached  with  great  difficulty  with  the 
finger.  But  in  cases  of  anteflexion  with  posterior  rotation 
the  OS  may  appear  to  be  in  its  natural  place.  In  the  latter 
instance,  however,  it  looks  upward  instead  of  downward. 
The  mere  fact  that  the  cervix  is  very  far  back  is  almost 
alone  sufficient  to  diagnosticate  anteversion. 
'  In  some  cases  which  have  come  under  my  notice  there 
has  evidently  been  a  misunderstanding  on  the  part  of  the 
attendant  as  to  the  significance  of  a  too  posterior  position 
of  the  cervix.  I  could  mention  cases  of  this  kind  which 
have  been  spoken  of  as  cases  of  retroversion,  simply  from 
inattention  to  the  proper  nomenclature  of  the  affection. 


324  DISEASES   OF  WOMEN. 

CHAPTER   XXIII. 

Anteflexion  and  Anteversion  of   the  Uterus — 
{ContiimecT). 

Treatment. — Important.  Differentiation  of  Cases  in  regard  to  Cause  of 
tlie  Affection — Tlie  Age,  tfie  Duration  of  the  Malady — Importance  of 
General  Treatment — Illustrations  of  Method  of  Treatment  necessary  in 
a  recent  Case — Positional  Treatment  very  Important:  How  to  be  car- 
ried out — Sitting  Position  to  be  avoided — A  more  Severe  Case — Com- 
bination of  Local  and  General  Treatment — Use  of  "  Cradle"  Pessary 
and  Sound — Case  in  which  Uterus  is  very  Rigid  and  Affection  of  some 
standing — Further  illustrative  Cases  of  Treatment  of  Anteflexion  after 
Pregnancy. 

Employment  of  "  Incisions"  of  the  Cervix — Former  Misconceptions  as 
to  Stricture  of  the  Cervical  Canal — Utility  of  the  Operation  in  Cases  of 
Flexions  considered — Necessity  for  Bougies  or  Stems  afterward — 
The  "Stem"  Treatment  considered — General  Conclusions — Difficulties 
in  Absolute  Cure  of  long-standing  Cases. 

Many  cases  of  anteversion  and  -flexion  can  be  cured  by 
general  treatment  alone — that  is  to  say,  by  a  scientific  ap- 
plication of  a  knowledge  of  the  laws  of  health  and  of  the 
laws  which  regulate  the  motion  of  the  uterus,  and  without 
the  necessity  for  local  manipulation  of  the  uterus.  But 
when  the  malady  has  existed  for  a  long  time,  and  when  the 
uterus  has  become  firm  and  hard  in  its  distorted  shape, 
there  is  nothing  inore  difficult  than  to  effect  a  perfect  cure, 
and  all  the  resources  of  mechanical  dexterity  are  required 
to  produce  a  thoroughly  satisfactory  result. 

The  general  treatment  of  flexions  (already  for  most  part 
fully  described  at  p.  224)  is  applicable  in  cases  of  anteflexion 
and  -version;  that  is  to  sa)',  the  diet,  the  general  health, 
regulation  of  the  bowels,  etc.,  require  great  care  and  at- 
tention. 

Many  cases  of  anteflexion  and  -version  can  be  success- 
fully treated  by  general  measures.  In  the  first  place,  how- 
ever, it  is  important  to  distinguish  between  {a)  cases  where 
the  symptoms  have  come  on  suddenly  and  plainly,  as  the 
result  of  some  accident,  injur}-,  strain,  fall,  etc.,  and  {b)  cases 
where  the  approach  has  been  more  gradual,  and  where  the 
case  is  evidently  one  of  general  weakness  {e.g.,  malnutri- 
tion), with  undue  mobility,  softness,  and  slight  flexion  re- 
sulting from  even  ordinary  exertion.     These  two  categories 


ANTEFLEXION  AND  ANTEVERSION  OF  UTERUS.   325 

of  cases  require  a  distinction  in  regard  to  treatment;  for  a 
severely  and  suddenly  displaced  uterus  is  as  much  a  proper 
object  of  surgical  attention  and  treatment  as  a  broken  limb. 
General  treatment  alone  would  be  as  a  rule  applicable  in 
the  class  b,  but  it  might  be  wholly  inappropriate  in  the 
class  a,  as  defined  above. 

Then,  again,  the  question  of  the  age  of  the  patient  affects 
the  decision  as  to  treatment.  Under  the  age  of  18  or  19 
general  treatment  would  be  preferred  to  local  treatment — 
and  for  very  sound  reasons:  one  is  obvious  enough  with- 
out necessity  for  mentioning  it.  Another  is  that  at  this 
age  a  slight  tendency  to  distortion  of  the  uterus  is  capable 
of  being  corrected  by  general  treatment  alone;  the  disease 
has  not  at  all  events  had  time,  as  a  rule  at  least,  to  become 
a  rooted  one.  Here,  however,  the  duration  of  the  suffering 
must  be  considered,  for  if  there  be  evidence  of  existence  of 
the  malady  for  two  or  three  years  and  the  illness  and 
incapacity  be  considerable,  the  age  should  be  no  bar  to  a 
proper  remedial  treatment. 

There  are  many  cases  occurring  at  17  or  18  in  which 
young  women  present  symptoms  clearly  indicating  slight 
degrees  of  anteflexion,  and  where  the  symptoms  have  not 
existed  more  than  a  few  months.  Such  cases  are  quite 
amenable  to  general  treatment. 

In  regard  to  cases  generall}'',  I  believe  that  the  duraiion  of 
the  malady  is  on  the  whole  a  good  guide  as  to  the  neces- 
sity for  local  as  well  as  general  treatment.  When  the 
duration  extends  over  a  year  or  two,  general  treatment  by 
itself  is  of  little  service,  though  very  necessary  as  an  ad- 
junct. Even  to  this  statement  there  is  an  exception,  for  if 
the  uterus  happens  to  remain  soft  during  the  whole  time  it 
is  still  comparatively  easy  to  make  it  assume  a  more  natu- 
ral form. 

The  majority  of  cases  require  for  their  treatment  a  com- 
bination of  general  and  local  treatment.  Above  all  they 
require  what  I  have  termed  a  "  mechanical  "  treatment;  by 
which  is  meant  not  necessaril}^  tlie  employment  of  mechani- 
cal apparatus  or  instruments  of  any  kind,  but  the  utiliza- 
tion of  the  action  of  the  force  of  gravit3\  It  implies  also 
the  utilization  of  the  conclusions  expressed  at  p.  112,  in 
respect  to  the  manner  in  which  flexions  cause  congestion  of 
the  uterus,  and  of  the  knowledge  that  the  congestion  is  to 
so  great  an  extent  a  natural  consequence  of  the  presence  of 
the  flexion,  and  can  be  "  mechanically"  removed  by  elevating 


326  DISEASES   OF  ^YOMEN. 

the  fundus  uteri,  that  elevation  being  effected  by  the  aid  of 
gravity  or  by  some  otlier  mechanically  acting  force. 

Dr.  Emmet  has  some  remarks  in  his  valuable  work  which 
show  the  great  importance  he  attaches  to  this  principle  of 
treatment.  Speaking  of  the  treatment  of  ulerine  displace- 
ments he  says,  "  Our  first  aim  should  be  to  give  tone  to  the 
pelvic  vessels,  and  to  place  the  uterus  in  a  position  where 
the   circulation   will  be   the   least  obstructed"  {op.   cit.,  p. 

144)- 

I  now  proceed  to  illustrate  the  application  of  general  and 
local  treatment  to  particular  cases. 

Thus,  a  young  lady  of  18  is  suffering  from  a  slight  ante- 
flexion. Duration  of  ill  health  one  year  only.  In  such  a 
case  as  this  a  proper  treatment  would  be  to  restore  the  nu- 
tritive activity  by  careful  feeding,  and  attend  to  the  general 
health;  in  the  next  place,  to  insist  on  the  maintenance  of 
the  recumbent  position  during  the  greater  part  of  the  day: 
the  patient  to  choose  a  chair  with  a  very  sloping  back,  or 
to  use  a  sofa;  to  walk  only  a  short  distance  at  a  time;  to 
avoid  all  exertions,  stooping,  lifting,  carrying,  etc.;  fresh 
air  as  much  as  possible,  baths,  friction,  etc. 

One  of  the  chief  points  in  the  above  treatment  is  the  posi- 
tional treatment  recommended.  Lying  down  is  in  fact 
most  important,  and  after  seeing  much  of  the  evil  results 
of  a  misjudged  "active-exercise"  treatment  in  such  cases  as 
the  one  mentioned  above,  I  have  no  hesitation  in  saying  I 
believe  it  to  be  essential  to  progress  in  the  right  direction. 
The  dorsal  recumbent  position  is  the  best.  This  may  be 
occasionally  modified  by  placing  a  pillow  under  the  lower 
spinal  region  to  elevate  the  pelvis  a  little;  and  the  knee- 
and-elbow  position  should  be  employed  several  times  in  the 
day  as  a  further  assistance.  Some  weeks  of  the  above 
treatment  are  generally  required  to  produce  much  effect. 
Change  of  air,  change  of  scene,  are  adjuvants,  but  it  is  a 
great  mistake  to  imagine  that  they  will  alone  and  unaided 
cure  the  patient  if  violent  exercise  be  permitted. 

The  sitting  posture  I  have  always  found  very  unsuitable 
in  cases  of  anteversion  and  -flexion — that  is  to  say,  sitting 
in  the  ordinary  position  in  an  upright  chair;  and  for  a  long 
time  I  have  found  great  advantage  from  advising  this  to 
be  as  much  as  possible  given  up  in  such  cases.  It  is  infi- 
nitely worse,  according  to  my  experience,  for  a  patient  to  sit 
at  table  or  at  meals  for  an  hour  than  to  go  for  a  long  walk. 
Sitting  is,  in  fact,  no  rest  to  the  patient,  and  the  flexion  is 


ANTEFLEXION  AND  ANTEVERSION  OF  UTERUS,  ^l"] 

thereby  exaggerated.  It  will  be  found  that  an  iron-frame 
chair  with  a  back  capable  of  being  let  down  to  an  angle  of 
45°,  whereby  the  vertebral  column  is  inclined  much  back- 
ward, is  excellent  for  patients  requiring  proper  rest,  and  it 
may  be  exchanged  for  the  sofa  when  desired.*    The  amount 

Fig.  87.f 


of  walking  to  be  done  depends  on  circumstances.  Twenty 
minutes  twice  a  day  would  be  suitable  in  the  case  above 
mentioned. 


*A  chair  admirably  adapted  for  this  purpose  is  sold  by  Williams,  41 
New  Bond  Street. 

\  Fig.  87  represents  the  cradle  pessary  in  situ.  The  case  represented 
was  one  of  a  nulHparous  uterus  in  a  highly  congested  state,  anteflexed  to 
second  degree,  with  much  anterior  rotation.  The  pessary  is  one  of  small 
size. 


328 


DISEASES   OF  WOMEN. 


The  knee-and-elbow  posture  is  of  considerable  assistance 
in  such  cases.  It  may  be  employed  for  five  minutes  at  a 
time,  five  or  six  times  a  day. 

AVe  may  next  take  a  more  severe  case.  The  patient  is  22 
or  27,  and  has  been  ill  for  some  three  or  four  years.     The 

Fig.  88  * 


uterus  is  anteflexed  to  the  second  or  third  degree;  there  is 
great  weakness;  the  uterus  is  soft  to  the  touch,  readily  re- 
placed by  the  sound,  but  returns  to  its  distorted  shape  on 
withdrawing  the  instrument. 


*  Fie-  88  represents  a  cradle  pessary  of  larp^e  size  as  in  action  in  a  case 
of  anteflexion  and  -version  in  a  patient  who  had  had  children;  uterus 
large  and  congested. 


ANTEFLEXIOX   AND   ANTEVERSIOX   OF   UTERUS.    329 

This  is  a  case  which  will  prove  most  difficult  to  cure 
unless  some  kind  of  mechanical  internal  treatment  be  had 
recourse  to.  The  recumbent  position  as  described  above, 
but  more  strictly  so  for  the  first  few  weeks,  is  required. 
Reposition  of  the  uterus  by  the  sound  every  third  or  fourth 
day.  At  the  end  of  ten  or  fourteen  days  introduction  of  a 
cradle  pessary,  which,  if  well  fitted  and  found  to  work  well, 
may  be  retained  for  some  weeks.  Details  as  to  the  pessary 
to  be  employed  will  be  given  later  on.  Use  of  sound  to  be 
continued  at  intervals  of  a  week  or  so,  the  object  being  to 
straighten  the  uterine  canal  more  completely.  For  this 
purpose  the  sound  is  inserted  nearly  straight.  It  should 
tlien  be  turned  gently  round  so  as  to  unbend  the  uterus, 
and  withdrawn  at  the  end  of  four  or  five  minutes.  Con- 
joint use  of  the  sound  and  the  pessary  may  be  found  diffi- 
cult to  carry  out  without  withdrawal  of  pessary,  and  in 
some  cases  it  may  be  better  to  dispense  with  the  sound  for 
some  weeks  at  first.  But  the  pessary  should  be  used  con- 
tinuously for  the  most  part,  or,  at  all  events,  if  it  be  removed 
for  a  day  or  two  the  patient  must  not  be  allowed  to  move 
from  the  horizontal  position,  otherwise  ground  gained  may 
be  lost,  for  the  action  of  a  well-acting  pessary  is  like  that 
of  a  splint,  keeping  up  a  continuous  rectifying  action  and 
preventing  movement  of  the  fundus  in  the  wrong  direction. 

After  a  period  of  a  month  or  six  weeks  the  patient  may, 
perhaps,  be  allowed  to  move  about  the  room  a  liille,  but 
not  to  sit  upright,  and  a  walk  out  of  doors  ma}"  be  per- 
mitted at  the  end  of  two  months.  Carriage  exercise, 
though  good  in  one  way,  is  very  bad  in  another,  for  unless 
the  recumbent  position  be  maintained  the  jolting  of  the 
carriage  is  most  distressing  to  the  patient;  a  little  walking- 
is  infinitely  preferable. 

The  further  treatment  will  consist  in  the  use  of  the  pes- 
sary, changed  from  time  to  time,  if  necessary,  for  one  more 
suitable  to  the  altered  condition  of  the  uterus,  or  to  allow 
of  occasional  use  of  the  sound;  and  it  is  probable  that  in 
such  a  case  as  that  described  it  will  be  necessary  to  con- 
tinue tlie  use  of  the  pessary  and  avoidance  of  the  upright 
sitting  posture  for  perhaps  a  year.  But  after  the  first  two 
or  three  months,  or  even  earlier,  the  patient  may  be  so 
much  better  as  practically  not  to  be  an  invalid. 

In  cases  where  the  uterus  is  very  soft,  but  the  case  other- 
wise as  represented  above,  the  use  of  the  sound  would  be 
less  necessary.     More  care  would  be  required  in  the  nutri- 


330  DISEASES   OF   WOMEN. 

tional  direction,  and  a  year  would  be  probably  not  enough 
to  produce  a  complete  cure:  not  because  it  is  so  difficult  to 
keep  the  uterus  in  place  and  in  shape  as  it  is  to  give  it  the 
strength  to  retain  its  place  and  shape  unaided. 

We  may  next  take  a  case  still  more  severe.  The  patient 
is  27  years  old;  there  is  anteflexion  to  third  degree,  anterior 
rotation  to  third  degree,  uterus  very  low  down  in  the  pelvis, 
OS  uteri  almost  touching  the  coccyx,  space  behind  symphy- 
sis filled  by  the  enlarged  uterus,  the  uterus  itself  hard  to 
the  touch,  introduction  of  sound  difficult,  unbending  of 
uterus  difficult  and  painful,  illness  six  or  seven  years  in 
duration. 

In  such  a  case  the  elevation  of  the  uterus  may  be  diffi- 
cult, so  also  the  unbending,  owing  to  fixation  and  hyper- 
trophy of  the  organ.  The  best  plan  to  adopt  in  such  a 
case  would  be  to  keep  the  patient  recumbent  on  the  back 
for  two  or  three  weeks,  using  daily  copious  injections  of 
quite  hot  water  and  employing  pressure  on  the  fundus  by 
means  of  the  finger  occasionally,  aiding  the  elevation  also 
by  the  knee-and-elhow  posture  from  time  to  time.  After  a 
few  days  the  treatment  by  the  sound  might  be  commenced, 
and  soon  a  cradle  pessary  might  be  used.  But  under  such 
circumstances  there  is  a  greater  risk  of  creating  irritation 
by  the  conjoint  use  of  the  sound  and  the  pessary,  and  the 
treatment  must  be  modified  accordingly.  Moreover,  we 
cannot  expect  to  advance  rapidly  in  the  first  part  of  the 
treatment,  for  the  hardness  and  fixity  of  the  uterus  are 
against  us.  Still,  by  the  aid  of  rest,  hot  water,  and  slight 
continuous  pressure  upward,  distinct  advance  is  gained, 
and  after  a  few  weeks  more  rapid  progress  is  possible.  The 
steel  dilating  instrument  described  at  page  232  (Fig.  48)  is 
a  valuable  aid  in  such  a  case  as  the  above,  for  the  uterus 
can  be  straightened  and  at  the  same  time  gently  dilated  by 
its  means,  and  the  two  processes  of  straightening  and 
gradual  dilatation  are  a  mutual  help  in  the  rectif3'ing  treat- 
ment. 

The  cases  just  mentioned  have  been  given  in  outline  only, 
and  with  the  v;ew  of  setting  forth  the  general  method  of 
treatment  which  I  have  found  most  serviceable  and  success- 
ful in  the  large  majority  of  cases,  details  as  to  treatment 
of  the  various  complications  frequently  present  being  post- 
poned for  separate  discussion.  Necessarily  hardly  two 
cases  are  alike,  and  each  case  has  to  be  treated  on  its  merits; 
and  the  outline  given  above,  therefore,  is  to  be   taken  a§ 


ANTEFLEXION  AND  ANTEVERSION  OF  UTERUS.  33 1 

representing  the  idea  of  principles  of  treatment  whicli  has 
seemed  to  me  applicable  to  very  many  cases.  With  slight 
differences  the  principles  in  question  may  be  extended  to 
other  cases  not  included  in  the  above  series. 

Take,  for  instance,  the  case  of  a  patient  who  suffers  from 
anteflexion  dating  from  the  birth  of  a  child  a  year  ago.  In 
such  a  case,  a  vaginal  pessary  for  a  few  months,  combined 
with  avoidance  of  the  sitting  position  for  a  month  or  so, 
will  probably  effect  a  cure. 

Similarly  an  anteflexion  dating  from  three  years  since  the 
birth  of  a  child.  Here  a  pessary  will  probably  not  be  suffi- 
cient— the  use  of  the  sound  will  be  required,  and  a  pro- 
longed rest  may  be  essential  to  produce  the  necessary 
change  in  the  shape  of  the  uterus.  In  such  a  case  in  all 
probability  there  would  be  considerable  hypertrophy  of  the 
wliole  uterus,  and  this  would  have  to  be  treated.  Without 
a  long  maintenance  of  the  horizontal  position  no  progress 
could  be  made,  because  the  patient  would  not  bear  the  pres- 
sure of  the  pessary.  There  would  very  probably  be  other 
complications  also  requiring  attention. 

Cases  of  Anteflexion  with  Posterior  Rotation. — In  these  cases 
great  difficulty  is  found  in  the  treatment.  When  the  uter- 
ine tissues  are  soft  a  well-adapted  cradle  pessary  answers 
very  well  in  some  cases.  A  stem  pessary  may  be  found 
suitable  where  the  cradle  does  not  fulfil  the  necessary  indi- 
cations. When  the  uterus  has  become  hardened  and  a  long 
time  has  elapsed,  a  continuous  dilatation  treatment,  asso- 
ciated with  use  of  a  cradle,  will  be  found  best,  according  to 
my  experience,  but  it  may  be  necessary  afterward  to  use  a 
stem  pessary. 

It  may  be  well  in  the  next  place  to  mention  cases  in  which 
care  and  caution  are  requisite  in  application  of  the  treat- 
ment by  means  of  the  sound  or  dilator,  either  alone  or 
along  with  vaginal  pessaries.  Where  the  flexion  is  of  very 
long  standing  (say  over  seven  years),  and  the  uterus  is  hard 
and  rigid,  and  the  patient  over  35  years  old,  there  is  a  dan- 
ger of  setting  up  irritation  by  the  repeated  use  of  the  sound 
or  a  metallic  dilator,  more  especially  if  a  vaginal  pessary 
be  used  at  the  same  time.  Indeed,  I  have  known  cases  of  this 
kind  in  which  even  the  sound  alone  could  not  be  used  at  all 
without  risk  of  inducing  an  attack  of  pelvic  cellulitis. 
These  considerations  lead  to  the  necessity  for  care  and  cau- 
tion in  attempting  to  extend  the  principles  above  mentioned 
to  cases  of  long-standing  flexion  with  a  hard  uierui, 


332  DISEASES   OF   WOMEN. 

In  view  of  the  facts  just  mentioned,  it  may  fairly  be  ques- 
tioned whether  it  is  not  preferable  to  employ  some  other 
method  of  treatment  than  those  above  described  in  cases 
of  long-standing  flexion — that  is  to  say,  either  incision,  or 
dilatation  by  means  of  tents,  and  subsequent  use  of  the  stem 
treatment,  in  order  to  obviate  the  difficulties  encountered 
in  these  exceptional  cases. 

There  are  two  other  methods  of  treatment  of  anteflexion 
to  be  described — (i)  Incision  of  the  cervical  canal,  and  (2)  ilie 
use  of  the  uterine  stem. 

These  methods  of  treatment  are,  according  to  my  expe- 
rience and  belief,  inferior  in  effect  and  general  applicability 
to  the  more  simple  methods  already  described.  On  this 
subject,  however,  opinions  differ  I  have  not,  at  all  events 
of  late  years,  employed  these  methods  to  any  considerable 
extent. 

Before  alluding  further  to  these  other  methods  of  treat- 
ment it  may  be  well  to  point  out  the  position  of  these  oper- 
ations in  regard  to  the  pathology  of  the  uterus. 

Incision  of  the  cervical  canal  had  for  its  primary  object 
the  relief  of  dysmenorrhoea,  or  the  cure  of  sterility.  And 
it  was  not  at  that  time  understood,  at  all  events  to  the  ex- 
tent it  now  is,  that  the  supposed  stricture  of  the  cervix 
uteri  which  the  incision  was  to  open  was  in  the  very  great 
majority  of  cases  due  to  acute  flexion  of  the  uterus.  And 
whereas  the  question  would  have  been  asked  some  few 
years  ago,  Is  such  an  operation  good  for  the  cure  of  dys- 
menorrhoea?— the  question  now  would  more  properly  be, 
Is  the  operation  capable  of  curing  the  acute  flexion  which 
is  the  cause  of  the  dysmenorrhoea  or  sterility,  or  both  ? 

It  by  no  means  follows  because  the  operation  was  founded 
on  a  misconception  that  it  was  really  a  bad  operation;  and 
it  is  well  known  that  in  many  cases  the  operation  was  tem- 
porarily successful,  while  in  a  few  its  success  was  more 
permanent.  But  in  estimating  its  value  we  must,  as  I  be- 
lieve, regard  it  from  a  different  point  of  view  to  the  original 
one. 

Incision  of  the  Uterine  Canal  as  a  Rcfiiedy  for  Chronic  Ante- 
flexion of  the  Uterus. — The  operation  consists  in  incising  the 
uterine  canal  from  within,  generally  on  the  two  opposite 
sides — the  incision  being  made  so  as  to  affect  the  part  of 
the  cervical  canal  at  and  below  the  internal  os,  and  being 
carried  downward  to  the  external  os  uteri  in  such  a  manner 
that  tlie  entrance  to  the  uterus  is  rendered  somewhat  fun- 


ANTEFLEXION   AND   ANTEVERSION   OF    UTERUS.    333 

nel-shaped.  The  depth  of  the  incision  is  such  as  to  allow 
of  the  free  passage  of  a  large  sound  into  the  uterus.  The 
cervical  canal  and  the  internal  os  uteri  are  then  plugged 
carefully  with  cotton  or  lint  saturated  with  an  antiseptic 
or  a  styptic  such  as  perchloride  of  iron.  The  plug  is  re- 
tained for  two  or  three  days,  and  then  a  solid  plug  or 
stem  is  inserted  so  as  to  maintain  the  degree  of  opening 
obtained  by  the  operation. 

Such  is  the  operation  in  its  general  outline,  though  the 
details  are  somewhat  differently  carried  out  by  different 
operators. 

The  permanent  value  of  the  operation  above  described 
depends  on  the  efficiency  of  the  subsequent  treatment.  It 
appears  that  in  most  cases  the  uterus  returns  to  its  previous 
condition,  or  nearly  so,  unless  the  subsequent  treatment  is 
continued  for  a  very  considerable  time.  The  edges  of  the 
incision  unite,  the  flexion  returns,  and  after  two  or  three 
months  have  elapsed  the  effect  of  the  operation  seems  to 
have  passed  off.  At  least  this  is  liable  to  be  the  case,  if  the 
flexion  is  of  long  standing — five  or  seven  years  or  upward. 
If,  therefore,  a  long-standing  flexion  be  thus  treated,  either 
a  stem  pessary  should  be  worn  continuously  for  many 
months  after,  or  a  combination  of  occasional  bougie  treat- 
ment, with  use  of  a  vaginal  pessary,  would  be  necessary. 
It  seems  to  me  that  in  very  obstinate  long-standing  cases 
of  anteflexion,  with  a  hard  uterus,  the  incision  treatment 
well  followed  up  is  capable  of  effecting  more  than  can  be 
effected  in  any  other  way.  But  at  the  same  time,  according 
to  my  experience,  the  cases  in  which  the  treatment  is  really 
required  are  few  in  number. 

With  reference  to  the  danger  of  the  incision  plan  of  treat- 
ment it  cannot  be  said  that  it  is  devoid  of  danger;  and  see- 
ing that  it  is  an  operation  for  which  it  could  be  rarely  said 
there  is  an  absolute  necessity,  the  possibility  of  a  fatal  re- 
sult should  certainly  be  duly  considered  in  undertaking  it. 

Details  regarding  the  incision  treatment  will  be  given 
separately  later  on. 

I  propose  in  the  next  place  to  speak  of  the  stem  treatment 
for  the  cure  of  anteflexion. 

I  have  in  the  course  of  practice  had  a  considerable  ex- 
perience of  stems,  and  some  few  j^ears  ago  employed  them 
frequently.  In  the  last  edition  of  this  work  I  described  an 
apparatus  for  the  purpose  which  has  been  extensively  em- 
ployed  since,   either  as  originally  described  by  myself  or 


334  DISEASES    OF   WOMEN. 

witli  certain  slight  modifications.  But  I  have  not  employed 
the  stem  treatment  in  a  large  number  of  cases  of  late  j'ears, 
having  preferred  for  most  cases  a  conjoined  treatment  by- 
vaginal  pessaries  and  use  of  the  sound  or  dilator. 

The  stem  treatment  is  applicable  in  cases  of  anteflexion 
as  a  means  of  retaining  the  canal  (a)  pervious  and  (/-') 
straight.  The  advantage  gained  is  the  certainty  of  these 
two  objects  being  secured  so  long  as  the  stem  is  worn. 
When  the  flexion  is  not  of  long  standing  the  use  of  a  well- 
adjusted  stem  for  a  few  months  will  very  possibly  result' in 
a  satisfactory  cure:  provided  that  it  excites  no  intercurrent 
irritative  attack,  that  the  general  treatment  of  t!ie  patient 
i.s  judicious,  and  steps  be  taken  to  nourish  and  strengthen 
the  body  generally.  In  such  comparatively  simple  cases, 
liowever,  equally  beneficial  results  without  the  same  lia- 
bility to  production  of  irritative  effects  can  be  procured, 
according  to  my  experience,  by  other  more  simple  measures. 

Taking  cases  of  a  more  severe  type,  where  the  flexion  has 
been  of  longer  duration,  the  stem  treatment  offers  in  such 
cases  advantages  which  will  probably  decide  many  gynae- 
cologists, at  all  events  occasionally,  to  employ  them.  In 
reference  to  the  dangers  of  the  stem  treatment  much  has 
been  said,  some  authorities  going  so  far  as  to  say  thev 
ought  to  be  abolished  from  practice.  Undoubtedly  fatal 
results  have  followed  their  employment,  and  it  is  difficidt 
to  say  how  far  these  fatal  results  have  occurred  from  want 
of  care  or  from  an  inherent  dangerous  tendency  of  the 
treatment. 

An  interesting  paper  on  the  subject  of  the  use  of  stems 
was  published  in  the  "American  Journal  of  Obstetrics,"  in 
1S77,  by  Dr.  Ely  van  de  Warker,  and  a  discussion  fol- 
lowed *  which  may  be  studied  with  advantage.  It  is  there 
shown  that  opinion  in  the  United  States  differs  very  much  on 
the  advisability  of  the  stem  treatment.  Dr.  Van  de  Warker 
gives  it  as  his  opinion  that  the  treatment  is  capable  of 
being  employed  under  conditions  which  govern  every  care- 
ful surgeon  in  the  use  of  any  other  mechanical  device:  that 
the  contra-indications  are  recent  pelvic  inflammation,  acute 
or  chronic  peritonitis,  extreme  hyperaesthesia  of  the  uterus, 
intolerance  of  its  cavity;  that  the  stem  should  not  be  con- 
tinuously worn  if  the  pressure  is  great  from  the  flexion; 
that  the  stem  should  be  so  short  as  not  to  touch  the  fundus; 


■'.\merican  Journal  of  Obstetrics,"  10,  p.  694, 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    335 

that  the  support  should  be  in  the  vagina  and  movable,  non- 
corrosive,  and  that  it  should  be  managed  by  an  expert.. 

I  give  the  above  resiane  oi  the  paper  because  it  appears 
to  me  to  be  a  fair  statement  of  the  question.  In  this 
country  the  stem  treatment  is  strongly  advocated  by  some 
able  gynaecologists,  Dr.  Routh,  Dr.  Granville  Bantock,  Dr. 
Wynn  Williams,  Dr.  Thomas  Savage  of  Birmingham,  and 
others. 

Dr.  Routh  insists  on  the  necessity  for  preparatory  treat- 
ment and  blood-letting,  in  some  cases  use  of  tents,  in  some 
use  of  the  hysterotome.  Dr.  Bantock  would  recommend  at 
first  use  of  sound,  tent,  or  bougie,  but  if  the  flexion  be 
acute  he  would  divide  cervix  by  incision  and  use  the  stem 
afterward.  Dr.  Playfair  states  that  he  uses  stems  in  ex- 
ceptional cases  only  and  when  constant  supervision  can  be 
exercised.  Dr.  Wynn  Williams  and  Dr.  Thomas  Savage 
state  that  they  have  very  largely  employed  the  stem  treat- 
ment and  without  any  bad  effect  resulting.  For  myself  I 
can  say  that,  having  employed  the  stem  treatment  in  many 
cases  of  anteflexion,  I  have  never  had  a  fatal  result. 

Some  further  remarks  appear  to  be  required  as  to  the 
action  and  value  of  the  stem  treatment  in  obstinate  cases 
of  anteflexion.  Care  should  always  be  taken  to  ensure  that 
the  fundus  of  the  uterus  be  kept  in  its  proper  position. 
For  this  reason  the  stem  must  have  a  vaginal  frame-work 
on  which  to  rest  and  to  which  it  shall  be  so  far  fixed  as  to 
retain  the  long  axis  of  the  uterus  in  its  proper  position,  and 
so  as  to  prevent  rotation  of  the  fundus  forward.  Unless 
this  object  is  secured  the  stem  treatment  is,  in  my  opinion, 
likely  to  turn  out  a  failure. 

Another  point:  inasmuch  as  the  stem  keeps  the  uterine 
canal  straight,  and  continuously  so,  the  compression  of  the 
tissues  of  the  cervix  which  is  the  result  of  long-continued 
acute  flexion,  is  put  an  end  to;  the  atrophy  has  a  chance  of 
being  remedied.  The  efficacy  of  treatment  by  the  sound  in 
this  respect  may  be  compared  with  that  resulting  from  the 
use  of  the  stem  as  follows: 

The  object  we  have  in  view  is  to  permanently  alter  the 
shape  of  the  cervical  canal,  which  in  long-standing  cases  is 
liable  to  be  much  atrophied  on  one  side.  By  the  repeated 
use  of  the  sound  we  are  able  to  bend  the  canal  in  the  oppo- 
site direction  to  a  slight  extent.  The  frequent  repetition  of 
this  process  (aided  by  the  vaginal  pessary)  in  time  produces 
a  considerable  effect,  because  by  means  of  the  sound  we  cm 


336  DISEASES   OF   WOMEN. 

do  more  than  actually  straighten  the  canal.  Thus,  by  fre- 
quently slightly  retroflexing  the  uterus  we  in  time  cure  the 
anteflexion.  This  is  undoubtedly  an  advantage  which  the 
sound  treatment  possesses  but  which  the  stem  does  not. 
On  the  other  hand,  the  stem,  when  once  introduced  and 
found  to  suit,  can  be  worn  for  a  long  time  during  which 
the  uterus  is  always  kept  straight,  and  repeated  manual 
treatment  is  not  required. 

The  cases  which  present  most  difficulty  in  the  way  of 
permanent  rectification  are  those  of  sterile  patients  with  an 
elongated  cervix  of  a  tapering  character,  but  very  much 
bent  upward,  so  that  the  os  looks  directly  upward.  It  is 
held  by  some  gynaecologists  that  this  is  a  congenital  condi- 
tion. Such  is  not  my  impression.  At  all  events  the  cure 
of  these  cases  is  confessedly  difficult.  A  short  way  of  deal- 
ing with  these  cases  is  that  originated  by  Dr.  Marion  Sims, 
consisting  of  cutting  along  the  middle  line  of  the  cervix  on 
its  posterior  wall  and  thus  opening  the  cervical  canal,  in  ef- 
fect shortening  the  cervical  canal  to  a  considerable  extent. 
This  practice  is  advocated  also  by  Dr.  Emmet,  and  has 
been  practiced  by  others,  but  so  far  as  can  be  gathered  the 
operation  has  not  been  by  any  means  always  successful  as  a 
cure  for  the  sterility  which  has  been  the  principal  reason 
for  undertaking  it. 

Speaking  generally  in  reference  to  the  treatment  of  cases 
of  anteflexion  it  must  be  understood  Xhdii  whcfi  the  7nalady 
has  existed  for  some  years  a  persistent  treatment  extending 
over  a  considerable  time  is  required  to  obtain  a  com- 
plete cure.  If  the  patient  becomes  pregnant,  that  is  a 
considerable  help,  for  unless  a  miscarriage  occurs  (which 
has  to  be  prevented)  the  uterus  in  its  expansion  and 
growth  is  favorably  affected  by  the  pregnancy.  But  after 
it  is  over  a  recurrence  has  to  be  guarded  against.  On  the 
other  hand,  if  pregnancy  does  not  occur,  the  use  of  a  vag- 
inal pessary  is  required  in  some  cases  for  a  year  or  two,  or 
even  longer,  to  maintain  the  effect  of  the  treatment.  It  is 
impossible  to  cure  along-standing  case  in  a  few  months  so 
far  that  the  patient  can  dispense  with  some  internal  support. 
In  process  of  time,  however,  the  uterus  can  be  consolidated 
in  its  improved  shape  and  position;  but  this  is  necessarily 
a  work  of  time,  and  it  is  unreasonable  to  expect  it  to  be 
otherwise. 

In  a  certain  number  of  chronic  long-standing  cases  of 
anteflexion  it  is  not  advisable  to  initiate  local  treatment  at 


ANTEFLEXION  AND  ANTEVERSION   OF   UTERUS.   337 

all  owing  to  the  length  of  time  required  for  treatment,  or 
other  reasons.  In  some  it  is  necessary  to  be  satisfied  with 
sustaining  the  uterus  a  little  so  as  to  prevent  further  de- 
scent or  flexion.  After  a  gentle  treatment  of  the  latter  kind 
it  is  sometimes  found  practicable  to  go  on  with  more  radi- 
cal measures. 


CHAPTER  XXIV. 

Anteflexion  and  Anteversion  of  the  Uterus — 
{Conti}iuca). 

treatment — {Continued). 

Pessaries  for  the  Treatment  of  Anteflexion  and  Anteversion. — 
The  Author's  "Cradle"  Pessary — Principle  of  its  Action — Two  Varie- 
ties, the  "Bar  Cradle"  and  "Crutch  Cradle" — Various  Sizes  re- 
quired— Various  Materials — Modification  in  Use  resembling  Gehrung's 
Pessary — Introduction  and  Removal  of  the  Cradle  Pessary — Precau- 
tions in  regard  to  its  Use — Dr.  Gaillard  Thomas's  Pessaries — Other 
Pessaries :  Playfair's,  Galabin's,  Fancourt-Barnes's,  Galton's — The 
Air-ball  Pessary. 

THE  CRADLE  PESSARY. 

The  "cradle  pessary,"  as  it  is  now  termed,  was  exhibited 
by  me  on  May  i,  1867,  to  the  Obstetrical  Society  of  Lon- 
don, and  is  figured  in  vol.  ix.  of  the  "Obstetrical  Trans- 
actions." The  instrument  had  been  used  by  me  for  three 
or  four  years  previously  and  I  have  now  employed  it, 
sliglitly  altered  from  the  original  shape,  for  upward  of  fif 
teen  years,  in  the  treatment  of  anteversion  and  anteflexion. 

The  cradle  pessary  acts  on  the  following  principle  :  It 
rests  on  the  vaginal  floor  at  two  points — one  near  the 
entrance,  one  high  up  behind  the  cervix  uteri — and  with 
tliis  basis  of  support  it  makes  pressure  upward  and  a  little 
forward  through  the  vaginal  roof,  about  midway  between 
the  cervix  uteri  and  the  symphysis  pubis. 

The  general  outline  of  the  cradle  pessary,  looked  at  side- 
ways, is  that  of  a  triangle  without  a  base.  The  triangle 
has  unequal  sides,  and  experience  has  shown  that  in  all 
cases  this  triangle  must  have  sides  whose  measurements 
have  a  certain  definite  relation  one  to  the  other. 

The  line  111  a  is  a  little  longer  than  111  d. 


338 


DISEASES   OK  WOMEN. 


In  the  instrument  as  first  exhibited  the  measurements 
were  a  little  different,  but  I  have  found  by  long  experience 
the  above  relation  of  the  sides  of  the  triangle  to  be  the  cor- 
rect one.  If  a  smaller  instrument  be  used  a  similar  propor- 
tion between  the  measurements  of  the  sides  must  be  pre- 
served. I  have  thought  it  necessary  to  give  very  precise 
details,  because  many  patterns  of  cradle  pessaries  are  sold, 
not  at  all  agreeing  either  with  the  original  shape  or  with 
that  now  given,  and  which  have  not  consequently  been 
found  satisfactory  b}'  many  who  have  employed  them. 

Most  of  the  instruments  sold  as  "cradle"  pessaries  have 
the  grave  defect  of  being  too  long  at  the  base — i.e.,  the  dis- 
tance A  to  D  (see  Fig.  89)  is  too  great — the  result  being  to 


..P\ 

distend  the  vaginal  canal  too  much.  The  part  which  rests 
on  the  vaginal  floor  (a  to  d)  should  not  exceed  in  length 
that  shown  below  for  the  largest  size.  In  the  smaller  sizes 
it  should  be  a  little  less.  A  second  defect  in  instruments 
sold  is  the  want  of  suflficient  elevation  of  the  apex  of  the 
triangle,  and  a  third  is  the  placing  of  the  apex  of  the  tri- 
angle exactly  midway  over  the  base  line  a  d.  The  proper 
triangle  is  not  an  equilateral  triangle  and  the  two  lines  a 
III,  D  III,  should  be  of  unequal  length. 

I  now  employ  two  forms  of  the  instrument,  one  of  which 
is  represented  in  Fig.  90,  and  the  other  in  Fig.  91. 
The  former  may  be  described  as  a  cradle  with  a  bar, 
the   other  as   a  cradle   with    crutches,  one    on    each    side  ; 


*  In  Fiff.  8g  are  shown  three  triangles.  The  largest  indicates  the  size 
of  the  largest-sized  cradle  pessary;  the  others  are  smaller.  The  base 
iine  is  that  of  the  vaginal  floor. 


ANTEFLEXION  AND  ANTEVERSIOX   OF   UTERUS.   339 

the  terms  "bar  cradle"  and  "crutch  cradle"  are  con- 
venient distinctiv^e  appellations.  The}^  require  to  be  of 
various   sizes.      Three    sizes    are    generally    applicable — 

Fig.  90.* 


No.  I  the  smallest,  No.  2,  and  No.  3  the  largest.     The  above 
figures  represent  the  No.  3  size  (largest). 

The  action  of  the  cradle  pessary  is  in  part  a  direct  action; 

Fig.  91. t 


exerting  pressure  upward  and  a  little  in  front  of  the  fundus 
uteri  it  tends  to  elevate  the  fundus  to  its  proper  position. 
Moreover,  by  occupying  a  certain  space  it  prevents  occu- 

*  Fig.  go  represents  a  larjje  size  bar  cradle  pessary. 
\  Fi<;.  gi  shows  a  large  size  crutch  cradle  pessary. 


340 


DISEASES   OF  WOMEN. 


pancy  of  that  space  by  the  fundus.  In  addition  to  this  it 
has  a  lever  action — it  draws  the  cervix  forward,  and  has 
therefore  a  tendency  to  produce  posterior  rotation  of  the 
whole  uterus.  The  part  of  the  pessary  making  pressure  is 
the  "bar"  or  "crutch,"  as'thecase  may  be.  Sometimes  one 
variety  answers  best,  sometimes  the  other.  The  crutch 
pessary  is  scientifically  the  superior  instrument,  as  it  pre- 
vents lateral  movement  of  the  fundus.  The  present  con- 
struction  differs  slightly   from   that  first    introduced    and 

Fig.  92.* 


represented  in  the  1872  edition  of  this  work  in  the  relative 
position  of  the  apex  of  the  triangle.  The  apex  is  now  a 
little  further  forward,  and  it  has  a  better  and  more  perfect 
action  when  in  position. 

In  the  crutch  variety  of  the  cradle  pessary,  it  is  highly 
important  that  the  surfaces  of  the  crutch   part,  which  is  in 

*  Fig.  92  represents  outline  of  cradle  and  uterus  to  show  its  action. 
This  drawing  is  different  from  the  one  in  the  last  edition  of  this  work  ; 
the  large  ring  should  be.  as  it  is  here  shown,  posterior  to  the  cervix.  A 
is  the  posterior  or  large  ring  of  the  pessary,  B  is  the  anterior  or  smaller 
ring- 


ANTEFLEXION  AND  ANTEVERSION  OF  UTERUS.  34I 

front  of  the  uterus,  should  be  opened  out  so  as  to  present 
a  concave  surface,  against  which  the  uterine   body  rests. 

Fig.  93.* 


This  part  of  the  construction  of  the  crutch  pessary  is  not 
evident  on  a  lateral  view.     It  can  only  be  seen  on  looking 

*  Fig.  93  shows  a  large  size  crutch  cradle  as  seen  from  above. 

f  Fig.  94  represents,  in  a  profile  view,  the  three  sizes  of  the  cradle  pes- 
sary marked  respectively  I,  II,  and  III,  such  as  may  be  readily  made 
from  various  sized  rings  bent  into  the  crutch  shape. 


342 


DISEASES   OF  WOMEN. 


at  the  pessary  from  above.    The  annexed  drawing  (Fig.  92) 
will  render  this  explanation  more  intelligible. 

In  practice   it  is  found   that  the  space  between   the  two 
crutches  a  and  b  has  sometimes  to   be  a  little  increased 


Fig.  96.* 


from  that  shown  in  the  typical  instrument.  And  it  is  very 
necessary  that  the  surface  of  the  crutches  be  well  rounded 
off,  otherwise  the  pressure  is  not  well  borne. 

As  regards  the  size  suitable  to  different  cases,  it  is  found 
that  in  patients  who  have  had  children,  a  large  size  (No.  3) 

*  FiR.  95  represents  a  medium  size  No.  2  crutch  cradle;  Fig.  96  a  full 
size  No.  3  cruicli  cradle. 


ANTEFLEXION  AND   ANTEVERSlON   OF   UTERUS.    34^ 

general!}-  suits  best,  while  in  others  a  smaller  size  is  re- 
quired. Again,  the  width  of  the  instrument  as  a  whole 
sometimes  requires  to  be  a  little  different  from  the  typical 

Fig.  97.* 


measurement.     In  single   wunitjii  a  narrow  cradle   pessary 
is  also  essential. 

The  cradle  pessary  is  made  of  various  materials  ;  the  best 


*  Fig.  97  represents  an  extra  thick  No.  3  size  spring  cradle  pessary. 
f  Fig.  98  is  another  view  of  the  same  pessary. 


344 


DISEASES   OF   WOMEN. 


material  for  both  the  bar  and  crutch  varieties  is  ebonite, 
Messrs.  Coxeter,  of  Grafton  Street,  have  been  at  some 
trouble  in  making  these  two  varieties  of  the  cradle  pessary 


Fig. 


99. 


in  ebonite  according  to  my  directions,  and  now  keep  ihcni 
in  stock.  The  crutch  variety  can  be  constructed  extempo- 
raneously of  copper  wire  rings  covered  with  india-rubber, 
and  this  admits  of  easy  modification  of  the  size  or  shape. 
Ebonite  is  a  very  cleanly  material,  though  its  hardness 
renders  it  in  some  ways  inferior  to  the  soft  rubber-covered 

*  Fig.  99  shows  a  large  (No.  3)  size  spring  cradle  pessary  in  action. 


ANTEFLEXION   AND   ANTEVERSION   OF   UTERUS.    34$ 

pessary.  I  have  employed  cradle  pessaries  of  all  these 
varieties  of  material  in  very  many  cases  during  several 
years,  and  find  that  the  great  secret  of  their  successful  em- 
ployment is  the  accurate  fitting  of  the  pessary,  and  the 
preservation  of  the  normal  relational  measurements  of  the 
triangle  to  which  attention  lias  been  already  drawn. 

There  are  certain   exceptional   cases  in  which   a  larger 

Fig.  100.* 


cradle  pessary  than   No.  3  may  be   required,  but  they  are 
really  exceptional. 

Spring  Cradle  Pessaries. — I  have  found  that  cradle  pes- 
saries made  of  German  silver  covered  with  india-rubber  are 
sometimes  preferable  to  others.  For  cases  where  greater 
facility  in  introduction  is  required  they  are  very  useful. 
Messrs.  Coxeter,  Messrs.  Meyer  &  Meltzer,  and  Mr.  Rus- 
sell have  made  these  pessaries   in  conformity  with   my  in- 

*  Fig.  100  exhibits  a  special  mode  of  using  the  cradle  pessary.  The  pes- 
sary is  a  little  flattened  to  adapt  it  to  this  particular  object. 


34^  DISEASES   OF  WOMEN.  _ 

structions.  These  pessaries  are  to  a  certain  extent  com- 
pressible and  are  thus  more  easily  introduced,  and  retain 
their  shape  after  introduction.  Fig.  99  represents  a  No.  3 
cradle  pessary  made  in  this  way.  The  particular  pessary 
here  shown  is  most  valuable  for  cases  where  the  uterus  is 
large  and  heav)'^  (as  in  cases  of  anteflexion  with  a  congested 
hypertrophied  uterus),  and  it  is  made  purposely  a  little  thick- 
er than  is  required  for  ordinary  cases.  Nos.  I  and  2,  made 
in  this  material,  are  of  course  smaller  than  the  one  here 
shown. 

Another  Way  of  using  the  Cradle  Pessary. — In  some  few 
cases  I  have  found  that  the  cradle  pessary  acts  very  well 
when  it  is  rotated  backward  so  as  to  place  the  part  whicli 
is  ordinarily  in  front  of  the  body  of  tlie  uterus  behind  the 
OS.  The  plan  acts  beneficiall)^  in  certain  cases,  but  gener- 
ally the  tilting  action  of  the  pessary  backward  is  too  strong 
and  may  convert  the  anteversion  even  into  a  retroversion. 
Fig.  100  shows  a  cradle  pessary  a  little  flattened,  so  as  to 
lie  better  on  the  vaginal  floor,  and  acting  as  above  de- 
scribed. 

Gehrung's  pessary  for  anteflexion  is  in  principle  very 
like  the  one  above  described.  I  append  Gehrung's  drawing 
of  his  pessary,  from  which  it  will  be  evident  that  the  two 
act  alike.  I  had  occasionally  employed  the  modification 
above  described  some  time  before  the  publication  of  Geh- 
rung's pessary. 

Introduction  of  tJie  Ordinary  Cradle  Pessary. — The  intro- 
duction of  the  cradle  pessary  is  not  very  easy  unless  certain 
points  are  attended  to.  The  large  ring  is  to  be  introduced 
first,  the  bar  or  crutch  being  at  this  time  close  to  the 
urethral  orifice.  When  the  large  ring  is  thoroughly  engaged 
in  the  vaginal  aperture,  pressure  must  be  made,  not 
upon  the  ring,  but  upon  the  bar  or  crutch  part  which  is 
close  to  the  urethra,  and  this  part  must  be  pushed  inward 
under  the  urethra,  giving  the  instrument  a  son  of  rotation 
backward.  This  little  manoeuvre,  when  properly  performed, 
pnjjects  the  cradle  pessary  completely  into  the  vagina, 
and  its  further  introduction  is  a  matter  of  great  ease,  as  it 
takes  its  proper  position  certainly  and  readily.  Unless 
these  precautions  are  observed,  the  introduction  may  be 
very  difficult.  It  is  best  to  place  the  patient  on  the  side 
with  the  knees  well  drawn  up,  and  a  good  deal  of  fresh 
lard  or  cold  cream  should  be  used  to  facilitate  the  opera- 
tion.    In  unmarried  patients   requiring  the  use  of   the  in- 


ANTEFLEXION   AND   ANTEVERSION    OF    UTERUS.    347 

strument  the  difficulties  of  introducing    the   pessciry   may 
render  necessary  the  aid  of  an  anaestlietic. 

In  cases  where  any  considerable  degree  of  resistance  is 
experienced  in  elevating  the  uterus  the  use  of  the  cradle 
pessary  must  be  accompanied  with  precautions  in  regard  to 
the  position  of  the  patient.  The  horizontal  position  is  quite 
essential  at  first.  The  sitting  posture  is  generally  more 
uncomfortable  during  the  first  few  weeks  of  wearing  the 
cradle  pessary  than  it  was  before,  and  must  be  generally 
avoided  for  a  time  at  least.  Although  the  instrument 
really  presses  on  the  bladder  it   rarely  produces  any  irrita- 


FlG.    lOI* 


) 


tion  of  this  organ.  The  instrument  sometimes  presses  a 
little  unduly  on  the  rectum  if  there  be  too  much  standing 
c;r  sitting,  and  the  action  of  the  bowels  is  frequently  a  little 
liindered  by  its  presence.  To  obviate  this  occasional  dif- 
liculty  a  daily  enema  is  the  most  appropriate  remedy.  The 
ebonite  instrument,  when  well  fitted  and  working  well,  may 
l)e  worn  for  months  without  difficulty  of  any  kind,  but,  until 
it  has  done  its  work,  will  of  course  require  to  have  its 
action  supervised  and  regulated.  But  when  a  cradle  pes- 
sary   made   of  a  hard   material  has   been   worn    for   some 

*  Fig.  loi  is  Gehrung's  drawing  of  his  anteflexion  pessary. 


348 


DISEASES   OF  WOMEN. 


months  it  should  be  removed  and  a  soft  cradle  used  for  a 
time.  When  the  soft  india-rubber  varieties  are  employed, 
more  frequent  changes  and  daily  injections  with  a  little 
antiseptic  fluid  may  be  required,  especially  just  after  the 
periods  are  over. 

The  removal  of  the  cradle  pessary  may  be  attended  with 
difficulty  unless  certain  precautions  are  employed.  The 
pessary  must  be  drawn  backward  toward  the  anal  aperture 
as  well  as  downward,  and  it  will  be  found  easier  to  remove 
it  by  hooking  the  forefinger  into  the  pessary  behind  and 
not  in  front  of  it. 

Various  other  pessaries  have  been  employed  in  the  treat- 
ment of  anteversion  and  -flexion.  Some  of  these  will  now 
be  mentioned. 


Fig.  102.* 


Fig.  103.  t 


Dr.  Gaillard  Thomas  employs  two  or  three  pessaries  of 
his  own  design.  The  principle  adopted  by  him  is  to  use  a 
Hodge-shaped  pessary  as  a  foundation,  and  a  bar  in  form 
of  an  arch  is  carried  from  this  in  front  of  the  cervix.  This 
arch  moves  on  hinges,  so  that  it  can  be  inserted  more 
readily. 

Some  of  Dr.  Thomas's  instruments  are  represented  in 
the  annexed  figures  taken  from  the  last  (5th)  edition  of  his 
work. 

Dr.  Thomas  has  also  now  an  instrument  which  is  a  com- 
bination  of  the   stem   with   a  vaginal   pessary.     It  differs 


*  Fig.  102  shows  one  form  of  Thomas's  pessary.      It  is  in  ebonite  in  a 
single  piece. 

■[  Fig.  103  shows  a  hinged  instrument  of  Thomas's  for  antefle.xion. 


ANTEFLEXION   AND   ANTEVEKSION   OF   UTERUS.    349 

little  from  the  shape  of  the  other  vaginal  pessary,  but  there 
is  a  sort  of  cup  wliich  supports  a  stem,  the  stem  being  of 
course  placed  in  the  uterus;  a  piece  of  thread  is  attached 
to  the  stem  to  facilitate  its  withdrawal  after  removal  of  the 
vaginal  part  of  the  pessary. 

There  are  other  vaginal  pessaries  which  have  been  in- 
vented for  the  treatment  of  anteversion  and  anteflexion, 
acting  by  pressure  through  the  vaginal  roof — viz.,  those  of 
Dr.  Playfair,  Dr.  Galabin,  and  Dr.  Fancourt-Barnes. 

Hitherto,  instruments  have  been  described  acting  wholly 
within  the  vaginal  canal;  other  instruments  have  been  em- 
ployed acting  from  without.  As  a  rule,  certainly,  any  in- 
strument of  the  latter  kind  is  objectionable  to  the  patient 
and  requires  constant  attention.  Dr.  Thomas  describes  a 
modification  of  Cutter's  pessary  for  retroflexion,  but 
shaped  so  that  the  pressure  is  applied  in  front  of  the 
uterus,  and  fixed  in  a  similar  way  by  means  of  a  tape  pass- 
ing from  the  stem  to  the  waist  behind.     Instruments  have 

Fig.  104.* 


been  employed  by  others,  the  fixed  point  for  which  is  ob- 
tained by  attaching  a  stem  to  a  pad  in  front  kept  in  place 
by  a  pelvic  band  passing  round  the  pelvis.  Dr.  Galton  ex- 
hibited such  an  instrument  at  the  Obstetrical  Society  of 
London  in  1874.  The  principle  of  this  latter  instrument  is 
similar  to  that  of  an  instrument  before  employed  for  pro- 
lapsus of  the  uterus,  and  in  some  very  rebellious  cases 
there  is  no  doubt  that  such  an  instrument  would  be  found 
very  useful. 

The  Air-ball  Pessary. — Some  few  years  ago  I  was  in  the 
habit  of  employing  an  air-ball  pessary  rather  extensively  in 
the  treatment  of  anteflexion,  and  I  still  use  it  in  a  few  cases 
where  the  cradle  pessary  is  for  various  reasons  not  found 
convenient. 

The  air-ball  pessary  is  a  very  efficient  instrument  up  to  a 

*  Thomas  anteflexion  pessary,  modified  by  Munde,  with  hinges  sunk 


350  DISEASES   OF  WOMEN. 

certain  point,  and  in  cases  where  the  uterus  is  very  heavy 
or  large,  or  very  sensitive,  it  is  very  serviceable.  The  in- 
strument is  an  india-rubber  ball  made  perfectly  7'0U7id,  and 
it  has  a  small  tube  attached,  by  means  of  which  it  is  inflated 
after  introduction.  The  tube  has  a  stop-cock;  and  a  brass 
air  syringe  which  fits  the  stop-cock  is  the  means  of  intro- 
ducing the  air.  The  apparatus  is  well  made  by  Messrs. 
Meyer  &  Meltzer.  The  pessary  is  made  in  various  sizes. 
The  average  size  required  for  married  patients  is  a  ball  one 
inch  and  three  quarters  in  diameter  when  not  distended. 
After  insertion  this  is  inflated  until  its  diameter  is  two 
inches.  This  precise  amount  of  dilatation  can  be  ensured 
by  introducing  it  empty,  having  ascertained  previously 
how  many  strokes  of  the  piston  of  the  syringe  are  required 
to  produce  the  necessary  degree  of  distension. 

It  is  extreme!)^  important  that  the  ball  should  be  quite 
round,  and  that  the  distension  should  not  go  beyond  what 
is  required.  A  two  inch  diameter  ball  sustains  the  uterus 
in  the  proper  manner,  but  if  larger  it  displaces  it  as  a  whole 
backward. 

One  drawback  to  the  air  pessary  is  the  presence  of  the 
tube  externally.  This  should  be  fastened  in  front  to  a 
piece  of  bandage  tied  round  the  waist.  Another  is  the 
liability  of  the  stop-cock  to  get  out  of  order,  when  the  air 
of  course  escapes.  But  when  properly  managed  it  is  a 
very  useful  instrument,  and  has  the  advantage  that  it  can 
be  readily  inserted  and  removed  by  the  patient  herself. 
Careful  instructions  should  be  given  in  order  that  the  pes- 
sarv  may  continue  to  act  properly. 

[Of  all  pessaries  the  inflated  air  bag  above  described  is 
the  least  satisfactory.  It  is  seldom  used  in  this  country, 
at  least  by  men  who  understand  the  principles  that  should 
guide  us  in  the  treatment  of  uterine  displacements.] 


LATERAL   DISPLACEMENT  OF  THE   UTERUS.        35  I 


CHAPTER   XXV. 

Lateriflexion,  Lateral  Displacement  and  Alternat- 
ing Ante-  and  Retroflexion  of  the  Uterus. 

Lateriflexion  of  the  Uterus. — Treatment. 

Alterxating    Ante-    and    Retroflexion. — Nature  of   these   Cases — 

Condition    of   the    Tissues    of   the    Uterus — Treatment,    General   and 

Mechanical. 

LATERIFLEXION    OF    THE    UTERUS. 

As  a  general  rule  flexion  of  the  uterus  is  very  decidedly 
either  forward  or  backward,  although  it  is  common  enough 
to  find  that  the  inclination  of  the  uterus  is  a  little  to  one 
side,  the  flexion  not  being  exactly  in  the  middle  line.  But 
in  some  few  cases  it  is  found  that  the  flexion  is  very 
markedly  in  a  lateral  direction.  I  find,  on  referring  to  my 
case-books,  that  during  six  years  the  uterus  was  in  a  con- 
dition of  decided  lateriflexion  in  three  cases — not  a  large 
number,  and  showing  that  the  condition  is  a  rare  one. 
The  relation  of  the  uterus  to  the  broad  ligaments,  and  its 
lateral  fixation  by  these  structures,  prevents  lateral  dis- 
placement. 

Of  the  three  cases  referred  to,  one  was  a  single  lady, 
aged  24,  who  had  been  thrown  from  a  horse  a  year  before 
applying  for  advice,  since  which  she  had  been  subject  to 
considerable  pain  and  incapacity  for  locomotion.  In  the 
other  two  cases  there  was  no  history  of  a  severe  accident; 
one  patient  was  46  years  of  age,  and  the  displacement  was 
of  long  standing;  the  other  was  only  18,  and  had  walked 
excessively  since  her  marriage,  two  years  previously. 

I  have  seen  other  cases  in  which  the  uterus  was  ante- 
flexed  and  distinctly  inclined  to  one  side;  but  these  are  not 
included  in  the  above  category. 

The  diagnosis  of  these  cases  can  only  be  certainly  made 
by  means  of  the  sound.  [We  rarely  use  the  sound  for  this 
purpose.     The  bi-manual  method  is  alone  sufficient.] 

Treatment. — The  treatment  I  have  found  successful  con- 
sists in  the  employment  of  the  sound,  whereby  the  uterus 
is  replaced,  and  a  careful  positional  treatment.  If  the 
uterus  is  inclined  to  the  left  side  the  patient  should  lie 
principally  on  the    right.      The  horizontal  position   is   of 


352  DISEASES  OF  WOMEN. 

course  requisite.  As  regards  the  use  of  pessaries  in  such 
cases,  it  is  not  easy  to  adjust  one  which  shall  carry  out  the 
indications.  When  the  uterus  is  decidedly  in  a  state  of 
lateriversion,  with  slight  inclination  forward,  a  cradle  pes- 
sary can  be  fitted  so  as  to  meet  the  difficulty.  For  this 
purpose  the  crutch  cradle  pessary  should  be  so  bent  that 
the  crutch  projects  more  backward  than  usual  on  the  side 
to  which  the  uterus  inclines.  The  stem  pessary  would 
undoubtedly  be  the  best  instrument  to  employ  when  the 
uterus  is  very  decidedly  bent  to  one  side. 


LATERAL    DISPLACEMENT    OF    THE    UTERUS. 

I  have  seen  a  few  cases  in  which  the  uterus  without  being 
flexed  was  displaced  very  decidedly  from  its  median  posi- 
tion in  the  pelvis,  this  condition  being  the  result  of  an  acci- 
dent or  fall  and  giving  rise  to  protracted  and  obscure  suf- 
fering. 

Thus  in  one  case  a  3-oung  lady  fell  down  stairs,  broke 
her  arm,  and  was  laid  up  for  some  time  with  it,  but  when 
she  attempted  to  walk  found  it  difficult  and  painful  to  do 
so,  and  she  became  affected  also  with  "hysterical"  symp- 
toms. The  uterus  was  found  packed  away,  as  it  were,  in 
the  left  posterior  corner  of  the  pelvis,  where  it  had  evi- 
dently lain  since  the  injury.  By  positional  treatment  the 
uterus  was  brought  to  the  middle  of  the  pelvis  with  satis- 
factory results. 

Another  patient  had  sustained  a  severe  fall  on  the  floor 
from  sitting  down  when  there  was  no  chair.  Obstinate 
pain  in  the  back  resulted,  and  it  was  subsequently  found 
that  the  uterus  was  driven  backward  close  to  the  sacrum, 
and  a  little  to  one  side. 


ALTERNATING    ANTE-    AND    RETROFLEXION. 

A  very  important  and  interesting  class  of  cases  is  that 
in  which  the  flexion  alternates  backward  and  forward. 

These  cases  are  by  no  means  rare. 

I  first  became  acquainted  with  this  alternating  variety  of 
flexion  eight  years  ago  while  attending  a  case  which  proved 
to  be  one  of  this  kind  and  which  was  under  observation  for 
a  considerable  time.  It  was  very  difficult  to  cure,  and  the 
facts  observed  from  time  to  time  in  connection  with  it  fur- 


LATERAL   DISPLACEMENT   OF   THE   UTERUS.        353 

nished  me  with  information  which  has  been  found  very 
valuable  in  other  similar  cases. 

These  alternating  cases  are  typical  cases  of  the  "  soft" 
uterus.  This  softness  is  the  result  of  malnutrition.  The 
case  above  alluded  to  was  that  of  a  lady  threatened  with 
phthisis,  and  in  a  low  state  of  nutrition  generally.  There 
was  very  intense  uterine  dyskinesia;  complete  inability  to 
walk  more  than  a  few  yards.  The  uterus  was  found  retro- 
flexed.  Treatment  for  this  retroflexion  was  for  a  time  suc- 
cessful, but  it  afterward  failed  and  it  was  then  found  that 
the  uterus  was  anteflexed.  Again,  a  fresh  adjustment  was 
made,  but  it  was  found  that  tlie  slightest  pressure  in  front 
produced  retroflexion,  while  the  slightest  pressure  behind 
the  uterus  produced  anteflexion.  Tlie  uterus  was  so  weak 
that  it  had  no  power  to  keep  straight.  After  observing 
these  oscillations  long  enough  to  be  aware  of  the  true  nature 
of  the  case,  a  peculiar  shaped  pessary  was  applied  which 
had  the  effect  of  simultaneously  giving  pressure  in  front 
and  behind  the  uterus.  When  this  was  got  into  proper 
working  order  the  patient  was  able  to  walk  and  a  cure  was 
eventually  obtained  by  supporting  the  uterus  and  carefully 
improving  the  general  health  by  suitable  dietar3^ 

I  may  mention  another  case  which  has  been  under  obser- 
vation for  the  last  eight  or  nine  years.  A  young  married 
lady  was  found  suffering  from  anteflexion,  coupled  with 
very  great  debility — chronic  starvation.  The  uterus  was 
treated  successfully  and  the  patient  had  her  first  child  about 
two  years  afterward.  After  the  pregnancy  was  over  the 
uterus  became  again  troublesome  and  a  cradle  pessary  was 
again  required;  a  second  pregnancy  with  subsequent  recur- 
rence of  the  flexion,  and  a  third  with  similar  result;  a  fourth 
pregnancy  occurred  after  a  longer  interval,  and  after  it  had 
ended  satisfactorily  the  patient  again  came  to  me  in  conse- 
quence of  feeling  ill  and  in  pain.  On  this  last  occasion  I 
found  to  my  surprise  that  the  uterus  was  not  anteflexed,  as 
I  expected  to  find  it  from  former  experience,  but  retroflexcd. 
This  extremely  interesting  case,  with  all  the  circumstances 
of  which  I  am  perfectly  familiar,  offers  an  example  of  a 
uterus  originally  very  soft  and  which  has  never,  spite  of 
repeated  pregnancies,  become  really  firm  and  solid.  The 
case  is  rare  and  probably  exceptional,  but  it  teaches  some 
valuable  lessons. 

I  have  seen  at  various  times  a  considerable  number  of 
cases   less   marked   than   those  above   described,   but  well 


354  DISEASES   OF   WOMEN. 

characterized.  In  some  of  these  cases  no  internal  support 
was  used,  the  alternating  flexion  being  nevertheless  ob- 
served to  occur.  In  other  cases  the  alternation  followed  on 
the  use  of  a  vaginal  pessary,  a  retroflexion  changing  to  an 
anteflexion  under  the  use  of  a  Hodge-shaped  pessary,  and 
the  opposite  result  following  from  the  use  of  a  cradle  pes- 
sary in  a  case  of  anteflexion.  This  is  a  very  important  cir- 
cumstance to  bear  in  mind,  for  a  pessary  which  does  its 
work  well  and  satisfactorily  at  first  may  be  found  afterward 
not  to  be  acting  well.  In  those  cases  where  this  unusual 
flexibility  of  the  uterus  exists  the  pessary  (properly  ap- 
plied) tilts  the  uterus,  not  only  into  its  place,  but  may  have 
the  effect  of  producing  the  opposite  kind  of  flexion. 

I  have  on  some  few  occasions  been  consulted  by  patients 
w^ho  have  been  subjects  of  retroflexion  and  treated  by  the 
Hodge-shaped  pessary  by  other  practitioners,  but  w^ere  still 
in  search  of  relief.  In  these  instances  I  have  in  five  or  six 
cases  found  that  the  uterus  had  gone  over  from  retroflexion 
to  anteflexion.  In  one  case  very  great  anxiety  and  trouble 
had  resulted  from  the  supposed  impossibility  of  giving  the 
patient  relief,  but  the  true  cause  was  found  to  be  the  over- 
action  of  the  pessar3\  This  over-action  may  of  course  in 
some  cases  be  real,  the  pessar}'  being  worn  too  long  or 
being  too  large,  but  that  explanation  does  not  apply  to  the 
cases  I  have  now  in  my  mind  in  which  it  was  certain  both 
tliat  the  original  diagnosis  was  right  and  that  the  pessary 
was  skilfully  adjusted. 

These  facts  offer  evidence  of  the  necessity  for  carefully 
regulating  the  action  of  vaginal  pessaries  and  for  ascertain- 
ing that  they  are  acting  as  intended.  This  can  only  be 
done  certainly  by  the  careful  use  of  the  sound. 

If  the  case  be  originally  one  of  anteflexion  and  a  Hodge- 
shaped  pessary  be  employed,  one  effect  is  very  likely  to 
occur — viz.,  an  exaggeration  of  the  anteflexion.  I  have 
met  with  cases  where  this  result  has  been  observed,  the 
Hodge  pessary  having  been  used  under  a  mistaken  notion 
of  the  nature  of  the  case. 

I'reatment  of  Alternating  Flexions. — These  peculiar  cases 
require  a  corresponding  peculiar  treatment.  Probably  the 
difficulty  is  capable  of  being  surmounted  in  more  than  one 
way.  Tiie  plan  which  I  have  followed  in  the  cases  which 
liave  come  under  my  notice,  and  which  has  been  successful, 
consists  in  using  a  pessary  which  is  a  combination  of  the 
Hodge  and  the  cradle  pessary.     It  might  be  described  as  a 


LATERAL  DLSPLACEMEXT   OF   THE   UTERUS. 


355 


cradle  pessary  with  the  posterior  ring  elongated  so  as  to 
resemble  the  corresponding  part  of  the  Hodge  pessary. 
The  accompanying  drawing  gives  a  better  notion  of  the 
instrument  than  a  description.     The  object  of  the  instru- 


FlG.    10= 


ment  is  to  give  a  support  both  behind  and  in  front  of  the 
uterus,  and  the  pessary  in  question  has  been  found  to  fulfil 
these  indications  in  the  cases  in  wliich  I  have  employed  it. 


In  some  of  these  cases  it  is  probable  that  the  pessary  known 
as  Fowler's  pessary  would  prove  serviceable.  This  is  an 
instrument  made  of  ebonite,  and  having  a  conical  or  funnel 

*  Fig.  105  shows  a  profile  view  of  the  "alternating"  flexion  instrument. 
A  should  be  placed  behind  the  cervix;  B  corresponds  to  the  vaginal 
aperture. 

+  Fig.  106  represents  a  ground  plan  of  the  same  instrument. 


356  DISEASES   OF  WOMEN. 

shape,  into  which  the  uterus  falls.  It  is  sold  in  various 
sizes. 

Another  instrument  Avhich  would  fulfil  the  indications 
required  is  the  stem  pessary.  I  have  not  employed  it, 
however,  in  the  cases  of  alternating  flexion  which  have 
come  under  my  notice,  having  found  the  arrangement  above 
described  to  answer  extremely  well. 

In  conclusion  it  must  be  stated  that  no  amount  of  pre- 
cision and  mechanical  skill  will  be  effectual  in  giving  relief 
in  these  cases,  unless  it  be  conjoined  with  great  care  and 
attention  in  regard  to  the  strengthening  of  the  uterus. 
Careful  and  incessant  nutritional  treatment  for  as  much  as 
a  year  or  more  will  be  required  in  a  case  of  alternating 
flexion  in  order  to  really  cure  the  disease.  If  this  latter 
element  in  the  treatment  be  neglected,  the  uterus  will,  after 
the  removal  of  the  pessary,  relapse  into  its  former  trouble- 
some condition. 


CHAPTER   XXVI. 

Incision   and   Dilatation   of   the   Cervical  Canal   of 
THE  Uterus — Stem  Pessaries. 

Incision  or  Division  of  the  Os  and  Cervix  Uteri. — Various  Methods 
of  performing  the  Operation — Means  for  maintaining  the  Canal  open 
afterward — Dangers  of  the  Operation — Treaiment  of  Cases  of  Imper- 
forate Os  Uteri. 

D11.AT.A.TION  OF  THE  Canal  of  the  Uterus. — Dangers  of  the  Proced- 
ure— Means  of  effecting  Dilatation — Various  kinds  of  Tents — Method 
of  Introduction — Metallic  Dilators. 

Stem  Pessaries. — Various  Kinds — Simple  Stems— Stems  with  support- 
ing Vaginal  Framework. 

incision  or  division  of  the  OS  and  cervix  uteri. 

Incision  or  division  of  the  os  and  cervix  uteri  is  an  opera- 
tion practiced  chiefly  for  the  relief  of  dj'smenorrhoea  or  for 
the  cure  of  sterility.  But  it  is  also  a  means  of  facilitating 
the  rectification  of  the  shape  of  the  uterus  in  chronic  cases 
of  distortion  of  the  organ. 

In  order  to  enlarge  t-he  calibre  of  the  uterine  canal,  Sir 
J.  Y.  Simpson  first  employed  a  metrotome  cache,  b)'  means 
of  which  he  effected  an  incision  extending  up  to  the  os  in- 


INCISION  AND  DILATATION   OF  CERVICAL  CANAL.   357 

ternum,  first  on  one  side  and  then  on  the  other.  The  knife 
was  guarded  until  the  instrument  had  been  introduced 
sufficiently  far.  Various  modifications  of  this  instrument 
have  been  employed.  Dr.  Greenhalgh's  metrotome  is 
double-bladed,  and  by  it  a  bilateral  section  of  the  cervical 
canal  is  made,  rather  wider  below  than  above.  Dr.  Barnes 
uses  scissors  to  open  up  the  lower  part  of  the  canal.  Mr. 
Coghlan's  metrotome  is  adapted  for  making  an  incision  of 
the  internal  os ;  it  has  a  probe  point,  and  is  then  flattened 
out  with  a  short  cutting  edge  on  each  side.  In  some  cases 
a  careful  use  of  a  very  small  probe  is  required  to  inform  us 
as  to  the  direction  in  which  the  cervical  canal  goes,  and  a 
narrow  director  is  now  and  then  useful  in  guiding  the  knife 
when  we  are  dealing  with  the  internal  os  uteri. 

It  is  very  desirable  to  limit  the  extent  of  the  incision  at 
the  external  os  uteri  as  much  as  possible.  There  is  no  doubt 
that  it  is  unwise  to  divide  the  cervix  widely,  as  was  formerly 
done  ;  and  it  is  only  necessary  to  incise  the  os  uteri  exter- 
num to  such  an  extent  as  to  admit  of  free  access  to  the  in- 
ternal OS  uteri,  and  of  the  manipulations  required  for  incis- 
ing it,  and  inserting  material  for  maintaining  the  aperture 
patent.  There  are  cases  in  which  the  os  externum  is  so 
small  that  the  wall  must  be  cut  quite  through  to  a  certain 
extent. 

The  external  os  may  be  incised  by  a  pair  of  curved  scis- 
sors or  by  Sims's  knife,  and  the  internal  os  by  the  latter  in- 
strument. During  the  operation  the  patient  is  on  the  side 
in  the  Sims's  position,  the  Sims  speculum  being  used,  and 
the  OS  drawn  down  by  the  tenaculum  or  hook. 

After  the  incision  a  small  pyramidal-shaped  piece  of  lint. 
Steeped  in  perchloride  of  iron  and  glycerine^  is  carefully 
packed  into  the  cervix,  and  to  retain  it  in  situ  a  piece  of 
wetted  bandage  a  yard  or  so  in  length  is  packed  in  the 
vagina.  The  bandage  is  drawn  away  at  the  end  of  twelve 
hours,  but  the  cervical  plug  remains  for  two  or  three  days. 
After  removal  of  the  cervical  plug  an  ebonite  plug  can  be 
inserted.  Some  operators  introduce  one  immediately  after 
the  incision.  The  difficulty  in  maintaining  the  aperture  is 
great,  and  has  been  mentioned  by  all  who  have  performed 
the  operation.  After  a  month  or  six  weeks  the  wound  may 
become  greatly  contracted,  but  the  canal  does  not  usually 
return  quite  to  its  former  dimensions. 

The  ebonite  stem  is  preferable  to  other  methods  for  pre- 
venting the  canal  from  closing  ;   for  to  maintain  the  patency 


358  DISEASES   OF  WOMEN. 

of  the  canal  at  the  situation  where  tlie  contraction  mostly 
happens — viz.,  at  the  internal  os — is  often  a  matter  of  ex- 
treme difficulty.  A  stem  of  ebonite  acts  in  a  double  capac- 
it}',  keeping  tlie  canal  straight  as  well  as  open. 

The  dangers  of  incision  of  the  cervix  uteri  *  are  as  follows  : 

1.  Hcemorrhage  is  liable  to  be  very  considerable  when 
the  uterus  is  deeply  incised  ;  but  this  is  not  likely  to  occur 
when  the  depth  of  the  cut  does  not  exceed  half  the  thick- 
ness of  the  uterine  wall.  Cases  in  which  haemorrliage  has 
been  troublesome  are  probably  cases  in  which  incisions  have 
been  made  deeper  tlian  this.  The  bleeding  is  generally 
capable  of  easy  control  by  means  of  the  plug. 

2.  The  danger  of  septicaemia  is  the  chief  one.  It  is  very 
slight  when  ordinary  precautions  are  taken.  Dilatation 
appears  to  be  dangerous  after  a  cutting  operation,  and  it  is 
probably  most  dangerous  when  the  incised  surfaces  are  cov- 
ered with  puriform  secretion.  It  may  be  connected  with 
undue  depth  of  the  cutting  operation.  In  any  case  it  is  no 
doubt  dependent  on  entrance  of  putrescent  material  from 
the  canal  of  tiie  cervix  into  the  cut  vessels  (veins  or  lym- 
phatics) of  the  uterus.  The  free  use  of  carbolized  oil  in 
manipulating  the  cervix  uteri,  and  especially  the  avoidance 
of  dilatation  during  the  few  days  after  the  operation,  are 
recommended. 

Treatmctit  of  Cases  of  Imperforate  Os  Uteri. — In  some  rare 
cases  the  os  uteri  is  imperforate  congenitally,  and  there  is 
no  outlet  for  the  menstrual  fluid.  And  the  os  uteri  may 
become  occluded  after  labor,  from  effects  of  operations,  etc. 
Under  these  circumstances,  also  in  cases  of  physometra,  we 
may  be  called  upon  to  evacuate  the  contents  of  the  uterus 
artificially. 

*  Dr.  Montrose  A.  Pallcn  (1S77)  gives  a  valuable  summary  of  the  sub- 
ject of  incision  and  division  of  the  cervix  uteri  for  dysmenorilioea  and 
sterility,  in  "Am.  Journ.  of  Obst.,"  vol.  x.  p.  364.  It  appears  that  Dr. 
Sims  has  since  1874  adopted  a  plan  of  incising  the  cervix,  and  then  dilat- 
ing it  directly  after  incision  by  a  dilator  ;  after  which  operation  he  in- 
serts a  plug  of  glass,  ebonite,  or  aluminium  into  the  cervix,  which  is  re- 
tained for  from  two  to  six  days  afterward,  together  with  iron  cotton. 
Dr.  Fallen  states  that  since  1865  he  has  himself  operated  337  times,  the 
incisions  varying  in  different  cases.  The  results  were  in  fifty  per  cent 
relief  of  the  dysmenorrhoea  and  thirteen  to  fourteen  had  children,  while 
a  quarter  were  not  benefitted.  In  three  cases  cellulitis  followed.  In  two 
death  occurred,  but  not  as  a  result  of  the  operation.  Comparing  these 
results  with  cases  in  which  Dr.  Fallen  used  tents,  it  appears  that  in  150 
cases,  where  tents  were  employed,  two  died  rapidly  of  mciro-peritonitis, 
while  fourteen  had  pelvic  cellulitis. 


INCISION  AND   DILATATION   OF   CERVICAL  CANAL.   359 

In  congenital  cases,  we  have  to  make  a  communication 
between  the  uterus  and  vagina  in  the  best  manner  the  cir- 
cumstances may  admit.  We  endeavor  to  find  the  os  uteri, 
and  not  succeeding  in  this,  search  is  made  for  the  cervix. 
We  may  fail  in  discovering  any  trace  of  either,  the  disten- 
sion of  the  uterus  having  obliterated  all  traces  of  it.  In 
such  a  case  a  point  is  to  be  chosen  which  is  nearest  the  sup- 
posed seat  of  the  cervix,  and  the  opening  is  to  be  made  at 
that  point,  taking  care  that  the  instrument  used  be  directed 
toward  the  centre  of  the  enlargement,  so  as  not  to  run  a 
risk  of  wounding  the  bladder  or  rectum.  In  reference  to 
the  manner  in  which  the  uterine  contents  are  to  be  allowed 
to  escape,  certain  precautions  are  necessary.  It  is,  I  con- 
sider, advisable  to  allow  the  fluid  to  escape  very  slowly. 
After  the  first  part  of  the  treatment — the  evacuation  of  the 
fluid — has  been  gone  through,  we  have  to  take  measures 
for  maintaining  the  canal  of  the  cervix  open.  This  is  not 
unfrequently  found  troublesome,  there  being  a  tendency  to 
reclosure  of  the  canal,  necessitating  a  new  operation.  Grad- 
ual dilatation  by  means  of  bougies  or  by  the  use  of  tangle 
tents  is  most  appropriate  under  such  circumstances. 

The  puncture  of  the  tumor  from  the  rectum  is  only  ad- 
missible in  cases  wliere  the  other  operation  from  the  vagina 
is  absolutely  impracticable. 

In  cases  of  acquired  occlusion  of  the  os  uteri  or  cervical 
canal, the  canal  is  to  be  opened  and  made  pervious  by  a 
carefully  performed  operation,  which  must  be  determined 
by  the  nature  of  the  case.  In  many  of  these  cases  it  is  pos- 
sible to  find  out  the  track  of  the  old  canal  by  means  of 
probes,  and,  if  this  can  be  done,  it  renders  further  proced- 
ures more  easy.  A  small  canula  and  trochar,  long  enough 
to  reach  the  uterus,  is  sometimes  necessary  to  evacuate  the 
fluid.  The  canal  once  opened  the  occasional  use  of  the 
sound,  or  of  graduated  metallic  bougies,  is  required  to  pre- 
serve its  patency. 


DILATATION    OF    THE    CANAL    OF    THE    UTERUS. 

Dilatation  of  the  uterine  canal  is  a  procedure  required  in 
a  certain  number  of  cases  and  for  various  reasons.  It  is  an 
operation  of  delicacy  and  not  seldom  attended  with  consid- 
erable difficulty.  And  it  is  a  procedure  which  is  not  unat- 
tended with  danger. 


360  DISEASES   OF  WOMEN. 

The  objects  for  which  the  operation  is  undertaken  are,  as 
ah'eady  remarked,  various:  To  facilitate  introduction  of  a 
stem-pessary,  to  relieve  dysmenorrhoea,  to  cure  sterility,  to 
explore  more  completeh'  the  uterine  cavity,  as  a  help  to- 
ward the  cure  of  anteflexion  or  retroflexion  of  the  uterus, 
etc. 

It  will  be  well  to  speak  in  the  first  place  of  the  dangers 
of  the  procedure.  The  great  danger  is  the  setting  up  of 
the  pyaemic  process,  or  local  cellulitis.  Sponge  tents,  under 
certain  circumstances,  cause  rapidly  fatal  pyaemic  disease 
and  peritonitis;  but  other  dilating  agents  are  also  capable 
of  producing  serious  or  even  fatal  illness  of  a  similar  kind. 
Abrasion  of  the  cervical  canal,  or  a  partly  healed  wound  of 
the  same,  appears  to  favor  occurrence  of  dangerous  symp- 
toms. A  wound,  or  laceration,  or  contusion  of  the  cervi- 
cal canal,  in  the  process  of  dilatation  may  lead  to  the  same 
result,  and  this  is  more  especially  liable  to  happen  when 
puriform  secretions  are  lying  either  in  utero  or  in  such  a 
position  that  they  obtain  ready  access  to  the  abraided  or 
lacerated  surface.  The  action  of  a  sponge  tent  is  rapid, 
and  the  stretching  of  the  cervix  produced  is  considerable; 
the  sponge,  if  not  rendered  antiseptic,  very  speedily  under- 
goes a  putrescent  change,  and  after  a  few  hours  is  gener- 
ally foetid.  The  expanded  and  partly  abraded  surface  of 
the  cervix  is  then  in  contact  with  the  putrescent  product, 
absorption  occurs,  and  serious  symptoms  set  in  forthwith 
— at  least,  this  result  may  occur.  Introduction  of  a  second 
sponge  tent  immediately  on  withdrawal  of  the  first,  espe- 
ciall}^  if  the  first  has  been  allowed  to  remain  as  long  as  two 
days,  is  still  more  likely  to  prove  prejudicial.  Repeated 
slight  abrasions  or  lacerations  of  the  cervical  mucous  mem- 
brane, liable  to  be  produced  by  use  of  bougies  or  by  me- 
tallic dilators,  may  give  rise  to  similar  results.  The  pres- 
ence of  a  wound  or  abrasion  of  the  cervix  seems,  so  far  as 
my  experience  goes,  to  be  the  predisposing  condition;  but 
the  presence  of  an  exciting  cause  such  as  putrescent  or  puri- 
form fluid  at  the  spot  so  abraded  or  wounded,  appears  to 
be  equally  necessary. 

In  illustration  of  the  foregoing  statements,  it  may  be 
mentioned  that  at  a  discussion  on  sponge  tents  at  the 
Philadelphia  Obstetrical  Society  in  December,  1873,  vari- 
ous cases  of  death  were  mentioned  by  speakers:  (i)  Death 
after  insertion  of  a  third  sponge  tent,  the  last  retained  two 
days,  patient   having  moved   contrary  to   order;   (2)    death 


INCISION   AND   DILATxVriON    OF   CERVICAL   CANAL.    361 

after  a  second  tent,  interval  being  two  days;  (3)  death  after 
a  third  tent,  interval  between  each  one  day;  (4)  death  after 
use  of  three  sponge  tents. 

Sponge  tents  are  unequalled  for  certainty  and  rapidity  of 
action,  but  must  be  used  with  great  care.  One  operation 
appears  to  be  safe  enougli,  but  not  so  a  repetition  of  opera- 
tions. Sponge  tents  are  sometimes  antisepticized  before 
being  used,  but  it  seems  difficult  to  render  them  certainly 
aseptic.  Sponge  is  certainly  better  adapted  for  cases  re- 
quiring quick  and  extensive  dilatation  than  for  cases  when 
slight  dilatation  only  is  needed.  Thus  it  is  not  easy  to 
thread  the  internal  os  as  a  primary  operation  in  cases  of 
acute  fiexion — the  stiffness  of  the  tent  becoming  often  lost 
before  it  has  passed  the  narrow  part  of  the  canal.  When 
sponge,  or  indeed  any  like  material,  is  employed,  carbolized 
injections  should  be  always  freely  employed. 

St-a  Tangle. — Tents  of  this  material,  first  introduced  by 
Dr.  Sloan  of  Ayr,  have  been  frequently  used  during  the  last 
few  years.  They  are  tolerably  manageable,  and  very  pow- 
erful in  action.  The  material  is  very  hard  when  dry,  and 
can  be  shaped  by  a  knife.  Tents  of  this  material  are  some- 
times made  hollow,  as  first  suggested  by  Dr.  Greenhalgh, 
to  induce  more  rapid  swelling.  When  the  uterine  canal  is 
much  fiexed  or  tortuous,  the  introduction  of  the  tent  is  not 
easy  unless  it  be  a  little  softened  before  introduction.  And 
under  any  circumstances  the  operation  is  one  requiring 
some  little  skill  and  attention  in  order  that  it  may  be  suc- 
cessfully carried  out. 

In  cases  where  it  is  required  to  dilate  the  cervical  canal 
extensively,  bundles  of  sea-tangle  tents  may  be  employed 
according  to  Dr.  L.  Atthill's  suggestion.  Such  a  dilata- 
tion may  be  required  in  order  to  obtain  access  to  an  intra- 
uterine polypus  or  fibroid  tumor. 

The  slippery  elm  and  tupelo  are  other  materials  from 
which  uterine  tents  are  constructed. 

In  introducing  a  sponge  tent,  the  lateral  Sims's  position  is 
the  best,  the  Sims  speculum  being  employed  and  the  os 
drawn  down  and  fixed  by  a  hook.  This  has  also  the  effect 
of  somewhat  straightening  the  uterus  and  thereby  facilitat- 
ing entry  of  the  tent.  An  instrument  such  as  that  shown 
in  Fig.  107  is  a  good  sponge  tent  introducer.  Six  or  eight 
hours  is  the  proper  time  for  the  action  of  the  tent:  it  must 
be  then  removed. 

Another  good  tent  introducer  is  Fig.  108,  in  which  a  me- 


3^2 


DISEASES   OF  WOMEN. 


Fig.  107. 


Fig.  108. 


INCISION  AND   DILATATION   OF  CERVICAL  CANAL.    363 

tallic  pointed  needle  supports  the  tent  during  introduction, 
and  is  readily  detaciied  from  it  when  it  is  well  placed  in  the 
cervical  canal. 

[The  forceps  are  preferable  because  the  tent  can  be  firmly 
held  at  any  angle.] 

In  order  to  procure  proper  dilatation  of  the  uterine  canal, 
the  tent  must  be  made  to  pass  through  the  internal  os  uteri 
and  be  there  maintained  while  it  is  at  work.  Otherwise  it  is 
found,  perhaps,  that  the  tent  has  slipped  and  no  material 
advance  is  made.  The  tent  should  of  course  be  long 
enough  to  reach  just  beyond  the  internal  os  ;  and  it  should 
project  a  short  distance  into  the  vaginal  canal.  It  should 
be  always  firmly  attached  to  a  silk  or  strong  hemp  liga- 
ture for  withdrawal. 

Another  method  of  dilatation  is  that  known  as  Mr.  Law- 
son  Tait's,*  consisting  in  introduction  of  a  series  of  three 
box-wood  conical  plugs  into  the  os  uteri,  and  applying 
pressure  thereto  from  the  outside  by  means  of  an  india- 
rubber  elastic  band.  The  first  plug  is  removed  after  a  few 
hours  when  it  has  done  its  work,  and  is  replaced  by  a  larger 
one;  the  second  by  a  third.  In  this  way  the  canal  is  grad- 
ually dilated.  The  plug  is  kept  in  place  by  a  vaginal  stem 
which  screws  on  to  the  plug,  and  the  elastic  band  is  at- 
tached to  this  stem  outside  the  vagina.  The  elastic  thread 
is  fi.xed  to  a  bandage  encircling  the  waist. 

Metallic  Dilators. — These  are  undoubtedly  convenient  and 
efficacious  in  cases  where  slight  dilatation  only  is  required, 
and  are  also  very  useful  in  the  treatment  of  chronic  flexions, 
especially  anteflexion.  A  set  of  metallic  bougies  regularly 
graduated,  very  applicable  for  these  purposes,  are  now  kept 
by  surgical  instrument  makers.  There  are  various  metallic 
dilators — Dr.  Marion  Sims's,  Dr.  Priestley's,  Dr.  Ellinger's, 
etc.  After  having  tried  several  of  these,  I  have  found  the 
most  serviceable  one  which  I  had  constructed  by  Coxeter 
some  few  years  since,  which  is  a  modification  of  one  origi- 
nally made  for  the  late  Dr.  Rigby  by  Mr.  Ferguson  of 
Giltspur  Street.  It  is  on  the  principle  of  a  glove-stretcher, 
and  can  be  inserted  wherever  the  ordinary  sound  can  be 
made  to  pass.  It  possesses  a  knob  like  that  of  the  ordinary 
sound  to  indicate  the  depth  of  insertion,  and  should  also 
have  a  slight  groove  cut  on  the  opposite  side  for  similar 
purposes.     After  insertion,  the  two  blades  are  opened  by 

*  Lancet,  November  i,  1879. 


3'^4  DISEASES   OF   WOMEN. 

Fig.  109.* 


Fig.  1 10.* 


*  Fig.  log:  Graily  Hewitt's 
uterine  dilator  (reduced).  Fig. 
no  shows  a  lateral  view  of  the 
part  of  the  instrument  which  is 
introduced  into  the  cervical  capiil 
(actual  si?e), 


INCISION   AND   DILATATION   OF   CERVICAL   CANAL.    365 
Fig.  III.*  Fig.  112.* 


B 


* 


Fig.  Ill  represents  Dr.  Priestley's  dilator. 
Fig.  112  represents  Dr,  Marion  Sims's  dilator. 


\66 


DISEASES    OF   WOMEN. 


a  screw  slowly  and  deliberately,  and  the  force  exercised  is 

expended  at  the  spot  where  it  is  most  needed — i.e.,  the  os 

Fig.  113.*  Fig.  ii4.f 


uteri  internum.     It   is  an    instrument  of  very  great  power, 
and  sliould   therefore  be  employed  very  carefully.     It  has 

*  Fig.  113  represents  Dr.  Chambers's  stem  and  apparatus  for  intro- 
duction.    ("Obst.  Jour.,"  vol.  i..  p.  2.) 

f  Fig.  114  represents  Dr.  Granville  Bantock's  stem  and  mechanism  of 
uiiroduciioii.     ("Obst.  Journ.,"  vol.  xiii.,  p.  i.) 


INCISION   AND   DILATATION   OF   CERVICAL   CANAL.    367 

the  great  advantage  that  it  does  not  slip  out  of  the  canal. 
I  employ  it  frequently,  but  am  careful  to  do  only  a  very 
little  at  a  time  with  it,  and  generally  to  allow  an  interval  of 
two  days  between  each  dilatation — that  is  to  say,  in  cases 
where  the  instrument  is  used  for  the  purpose  I  most  com- 
monly employ  it,  in  the  treatment  of  a  chronic  flexion,  and 
with  the  view  of  permanently  straightening  a  tortuous  and 
contracted  canal. 

UTERINE    STEMS. 

Uterine  stems  may  be  divided  into  two  classes — (i)  Those 
which  are  intended  to  be  used  alone,  and  (2)  those  which 
are  used  in  conjunction  with  a  supporting  vaginal  disk  or 
framework. 

Simple  Stems. — These  are  generally  provided  with  a  small 
button-shaped  portion,  which,  when  the  stem  is  in  position, 
rests  on  the  vaginal  floor. 

With  few  exceptions  the  material  employed  has  been 
rigid — ebonite  (hard  rubber),  metal  of  various  kinds,  and 
glass  (Dr.  Meadows). 

Various  Shapes. — Dr.  Chambers  recommends  a  modification 
of  the  late  Dr.  Henry  G.  Wright's  stem.  It  is  a  vulcanite 
stem,  double;  but  the  two  arms  are  kept  together  until  the 
stem  is  inserted  by  the  stylet.  Withdrawal  of  the  stylet 
allows  the  arms  to  separate,  and  the  opening  out  of  the 
two  arms  prevents  the  escape  of  the  stem. 

Dr.  Granville  Bantock's  stem  is  partly  of  vulcanite,  and 
the  intra-uterine  part  consists  of  two  arms  of  German 
silver;  these  latter  spring  apart  and  retain  the  stem  after 
introduction. 

Dr.  Clement  Godson's  stem  is  of  aluminium,  made  in  five 
sizes;  it  is  retained  by  a  spring  within  the  tube,  which  pro- 
jects at  apertures  near  the  extremity  and  within  the  uterus. 

Mr.  Lawson  Tait's  stem  is  a  galvanic  instrument  with  a 
slight  projection  of  india-rubber  to  act  as  a  retaining  agent. 

Dr.  Alfred  Meadows's  stem  is  of  glass  with  a  small  button 
of  ebonite. 

A  quite  elastic  stem,  composed  of  india-rubber  tubing, 
vi^as  recommended  by  the  late  Dr.  Squarey. 

Stem  with  Supporting  Vaginal  Framework. — The  instrument 
here  figured,  which  has  been  sometimes  termed  the  "  pad- 
lock" pessary,  was  devised  by  myself,  and  described  in  the 
last  edition  of  this  work  (1872).     Fig.  117  shows  at  b  tlie 


?68 


DISEASES   OF   WOMEN. 


Stem  of  ebonite,  one  and  a  half  inches  in  length,  the  lower 
portion  hollow  to  admit  the  inserting  stylet.  At  A  is  shown 
the  supporting  vaginal  disk,  of  an  oval  outline,  having  a 
socket  into  which  the  stem  fits  when  in  situ.  The  stem  is 
intended  to  fit  rather  loosely  in  its  socket.  The  plug  or 
stem  which  I  have  employed  for  this  purpose  is  one  and 
three  quarter  inches  long,  conical   in  shape,  with  a  bulbed 


Fig.  115. ■^ 


Fig.  ii6.t 


termination.  The  diameter  varies;  the  smallest  has  a 
diameter  of  three  sixteenths  of  an  inch  at  its  bulbed  ter- 
mination. The  stem  ends  below  by  a  broad  basis  half  an 
inch  in  diameter,  and  is  perforated  for  a  short  distance  for 
facility  of  introduction,  the  ordinary  uterine  sound  fitting 
into  the  perforation,  and  acting  as  a  handle.      The  stem   is 

*  Fig.  115  shows  Dr.  Clement  Godson's  stem.     ("Obst.  Journ.,"  vol. 
.xvii..  p.  2S6. 

j-  Fig.  116  represents  Mr.  Lawson  Tftit's  stem. 


INCISION   AND    DILATATION   OF   CERVICAL. CANAL.    369 

retained  in  its  place — for  it  has  a  great  tendency  to  slip  out 
— by  the  oval  support,  made  to  fit  the  vaginal  canal. 

In  order  to  introduce  the  instrument,  the  sound,  as  a  han- 
dle, is  passed  through  the  collar  of  the  vaginal  framework, 
and  on  it  is  placed  the  ebonite  plug.  After  the  plug  is 
placed  in  situ,  the  ring  is  made  to  slip  up  the  sound  until 
finally  the  little  plug  finds  its  place  in  the  supporting  collar. 
The  sound  is  then  withdrawn  and  the  work  is  done.  Only 
those  who  have  attempted  to  introduce  rigid  plugs  into  a 
contorted  or  contracted  canal,  and  to  maintain  them  there, 


Fig.  117.* 


will  appreciate  the  necessity  or  usefulness  of  this  contri- 
vance, which  I  have  found  to  answer  extremely  well.  This 
instrument  is  made  by  Coxeter  &  Son.  I  have  found 
that  it  works  well  in  practice,  and  it  has  been  very  largely 
employed  by  Dr.  W.  Murray  of  Newcastle-on-Tyne;  the  vag- 
inal part  requiring  to  be  generally  one  and  three  eighths 
inches  by  tw'o  and  three  eighths,  but  sometimes  smaller. 

Dr.  Routh's  instrument  is  on  the  same  principle.  His 
stem  is  articulated  to  a  cross-bar  attached  to  a  Hodge  pes- 

*  Fig.  117  represents  Graily  Hewitt's  stem  pessary  (so-called  "pad- 
lock" pessary).  B  is  the  stem  (actual  size):  A  shows  the  stem  fitted  into 
the  supporting  vaginal  framework  (reduced  in  size).  As  at  present  made 
the  framework  is  more  flattened  than  it  here  appears. 


!;o 


DISEASES   OF   WOMEN. 


sar}',  its  position  in  regard  to  which  can  be  regulated  by  a 
screw. 

Dr.  Wynn  Williams's  instrument  is  another  modification 
of  the  same  principle.  In  his  pessary  the  vaginal  frame- 
work is  of  wire,  covered  with  india-rubber,  and  admits  of 
lateral  compression.  It  has  an  india-rubber  diaphragm  per- 
forated with  holes,  the  stem  is  set  near  the  distal  part  of 
the  vaginal  supporting  framework.  In  a  more  recent,  im- 
proved form  the  stem  rests  in  a  cup-shaped  depression  in 

Fig.  1 1 8.* 


the  diaphragm.  It  is  very  easily  applied  and  is  a  very 
ingeniously  constructed  instrument. 

Dr.  Meadows's  instrument  is  on  alike  principle,  and  also 
allows  a  certain  degree  of  motion  of  the  stem  on  the  frame- 
work. 

Dr.  Thomas  describes  a  combination  of  stem  with  an 
anteversion  pessary  which  he  has  found  useful  in  certain 
cases. 


*  Dr.  Wynn  Williams's  stem  pessary.     "  Obst.  Trans.,"  vol.  xiv.,  p. 
308. 


PREGNANCY   WITH  FLEXIONS  OF  THE  UTERUS.   3/1 


CHAPTER  XXVII. 

Association  of  Pregnancy  with  Flexions  of  the 
Uterus. 

General  Observations. — Frequency  of  Abortions  in  such  Cases:  Rea- 
sons for  this — Difficulty  of  Expansion  of  the  Uterus. 

Retroflexion  AND  Retroversion  of  the  Gravid  Uterus. — i.  Flexiort 
before  Pregnancy  occurs — Natural  History,  Symptoms,  and  Effects. 
2.  Flexion  occurring  after  Pregnancy  has  commenced — Diagnosis — 
Treatment — Reduction  by  Positional  Treatment;  by  other  Means — 
Treatment  of  the  Bladder. 

Anteflexion  of  the  Gravid  Uterus— a  Frequent  Condition  and  a 
Frequent  Cause  of  Abortion. — i.  Cases  where  the  Anteflexion  occurs 
after  Pregnancy  has  begun — 2.  Anteflexion  precedes  the  Pregnancy — 
History  of  these  various  Cases — Reasons  why  the  Complication  is  not 
generally  recognized  as  an  important  one — Diagnosis — Severe  Nausea 
a  Common  Symptom — Author's  Views  on  ihis  Subject — Retention  of 
Portions  of  Ovum  another  Result  of  the  Flexion — Treatment  in  various 
Cases  according  to  severity  of  the  Case — Elevation  of  the  Uterus,  how 
to  be  effected — Relief  of  the  Sickness — Mains  operandi  of  the  Treat- 
ment— Dr.  Copeman's  Method — Dilatation  of  the  Cervix  for  Cure  of 
Sickness  discussed  and  explained. 

Subsequent  Treatment. 

The  subject  of  the  association  of  flexions  witli  pregnancy 
is  a  very  interesting  and  important  one.  Retroflexion  of 
the  uterus  associated  with  pregnancy  has  been  long  known; 
but  concerning  the  association  of  anteflexion  with  preg- 
nancy little  has  been  published. 

When  the  uterus  is  in  a  flexed  condition  pregnancy  may 
not  occur  at  all.  When  pregnancy  does  occur  under  such 
circumstances,  the  result  varies  in  different  cases.  It  is 
necessary  to  point  out,  and  to  endeavor  to  explain,  the 
various  results  observed  in  different  instances. 

If  tiie  flexion  be  slight  in  degree  and  not  of  long  duration 
(say  not  over  two  years),  pregnancy  may  proceed  to  the 
full  term.  It  is  generally,  however,  noted  in  such  cases 
that  the  early  part  of  the  pregnancy  is  attended  with  a 
troublesome  amount  of  nausea,  and  there  may  have  been 
o;!ier  discomforts  observed  as  soon  as  pregnancy  set  in. 

When  the  flexion  is  more  chronic  or  more  severe  in  de- 
gree, it  generally  happens  that  an  abortion  occurs  during 
the  second,  third,  or  fourth  month. 

The  pregnancy  may  begin  before  the  uterus  becomes 
affected    with   flexion.     There   are  instances  in  which  the 


3/3  Diseases  of  women. 

uterus,  having  been  in  a  normal  condition,  becomes  gravid, 
and  soon  after  falls  into  a  flexed  condition. 

In  cases  where  abortion  happens  during  the  early  months 
of  pregnancy,  we  cannot  tell  without  a  careful  inquiry  into 
the  previous  history  aud  other  facts  whether  the  flexion 
followed  the  pregnancy  or  preceded  it. 

Abortion  is  a  very  frequent  result  of  the  association  of 
pregnancy  with  uterine  flexion,  and  such  association  is 
really  the  most  common  of  all  the  causes  of  abortion. 

The  reason  why  abortion  is  so  liable  to  occur  in  cases 
where  the  uterus  is  flexed  appears  to  be,  principally,  the 
interference  which  the  distortion  of  the  uterus  offers  to  the 
proper  expansion  of  the  cavity.  But  the  distortion  would 
have  very  much  less  influence  than  it  is  found  to  have  if 
the  body  of  the  uterus  were  free  to  move.  Owing  to  the 
action  of  gravity  on  the  one  hand,  and  the  hindrance 
offered  to  the  ascent  of  the  uterine  fundus  by  the  sacral 
promontory  (in  cases  of  retroflexion),  and  by  the  symphysis 
pubis  (in  cases  of  anteflexion),  the  uterus  is,  however,  not 
free  to  move  and  expand  in  the  normal  manner. 

If  we  suppose  the  uterine  walls  to  be  in  a  condition  of 
health,  the  conditions  just  mentioned  above  would  be  the 
only  ones  to  be  considered.  Given  freedom  to  expand  and 
space  in  which  to  expand,  there  would  be  no  reason  why  the 
uterus,  though  bent  upon  itself,  should  not  unbend,  expand, 
and  do  its  proper  work  in  the  ordinary  manner — the  above 
difficulties  being  removed. 

But  in  many  cases  we  have  further  obstructive  conditions. 
When  the  flexion  is  a  chronic  one,  the  uterine  walls  are 
liable  to  become  changed  in  thickness,  and  in  other  respects. 
Too  thick  in  some  parts,  unduly  thin  in  others,  corrugated, 
compressed,  sometimes  constricted  on  the  peritoneal  surface 
by  adhesive  bands, — under  such  circu  mstances  the  expansion 
of  the  uterus  is  a  matter  of  difficulty,  and  an  abortion  may 
result  at  an  early  period  of  the  pregnancy. 

There  are  good  reasons  for  believing  that  in  some  cases 
the  difficulties  in  the  expansion  of  the  uterus,  though  not 
immediately  resulting  in  expulsion  of  the  ovum,  produce 
interference  with  the  placental  growth  in  such  a  way  that 
premature  labor  and  delivery  of  a  dead  child  occur  later 
on. 

The  hardening  and  compression  of  the  uterine  tissues  re- 
sulting from  flexion  are  more  particularly  liable  to  be  pres- 
ent near  the  os  uteri  internum,  and  there  are  various  curious 


PREGNANCY   WITH    FLEXIONS    OF   THE   UTERUS.    373 

clinical  facts  hereafter  to  be  mentioned  which  are  only  to  be 
interpreted  by  supposing  a  condensation  of  the  uterine  tis- 
sues to  exist  at  this  situation.  If  the  puckering  and  con- 
densation be  considerable,  it  is  evident  the  uterus  may  be 
so  held  and  maintained  in  its  distorted  condition  that  ex- 
pansion of  the  organ  is  difficult.  The  difficulty  in  question 
finds  a  solution,  in  many  instances,  in  the  occurrence  of 
abortion. 

But  a  further  result  of  the  existence  of  acute  flexion  is 
probably  actual  disease  of  the  decidua  vera,  and  consequent 
abortion  brought  about  in  this  way.  The  growth  of  the 
decidua,  wliich  is  a  part  of  the  natural  process  of  preg- 
nancy, cannot  proceed  normally  at  certain  situations,  and, 
as  has  been  shown  by  examination  of  actual  specimens,  it 
may  become  actually  disorganized,  and  thus  lead  to  the 
occurrence  of  abortion.  Such  is  probably  the  explanation 
of  two  very  interesting  observations  made  by  Dr.  Slav- 
jansky,  and  published  in  1873,  entitled  "  On  Endometritis 
Decidualis  Chronica  as  a  Cause  of  Abortion  in  some  cases 
of  Displacement  of  the  Pregnant  Uterus."  * 

AH  cases  of  uterine  flexion  in  which  pregnancy  occurs 
are  not  followed  by  abortion,  but  it  is  mechanically  almost 
impossible  for  pregnancy  to  continue  if  the  flexion  be  un- 
relieved. As  a  matter  of  fact,  many  cases  of  this  kind  are 
so  relieved;  the  uterus  becomes  straight  by  expansion.  In 
others  the  flexion  remains,  and  as  the  uterus  goes  on  ex- 
panding the  result  is  in  many  cases  to  actually  increase  the 
flexion. 

RETROVERSION     AND    RETROFLEXION  OF    THE  GRAVID    UTERUS. 

Desgranges  (1715),  Gregoire  (1746)  and  William  Hunter 
(1754),  described  cases  of  "  retroversion"  of  the  gravid  uter- 
us. Gooch  in  his  lectures  (quoted  by  Ashwell,  "  Disear.cs 
of  Women,"  p.  597)  gives  a  full  narrative  of  William  Hun- 
ter's celebrated  case.  In  this  case  the  patient  was  four  months 
pregnant,  when  she  began  to  suffer  from  retention  of  urine. 
This  was  relieved  by  catheter  but  again  occurred.  Mr. 
Wall,  who  was  the  medical  attendant,  recognized  the  case 
as  one  like  that  published  by  Gregoire.  He  tried  to  reduce 
the  retroverted  uterus,  but  failed,  and  then  sent  for  William 
Hunter,  who   recognized  the  nature  of  the   case   also,  and 

*  Paper  read  before  the  Obstetrical  Society  of  Edinburgh,  July,  1873. 


374  DISEASES   OF  WOMEN. 

attempted  reduction  unsuccessfully.  There  was  obstinate 
constipation.  The  patient  died  in  a  few  days.  A  second 
case,  it  appears,  occurred  soon  after,  and  the  patient  could 
pass  neither  urine  nor  faeces.  The  catheter  could  not  be 
introduced;  it  was  proposed  to  puncture  the  bladder;  the 
patient  refused,  and  at  length  felt  something  burst,  which 
proved  to  be  the  bladder,  and  she  expired  in  a  few  hours. 
In  both  these  cases  the  state  of  the  uterus  was  substantiated 
by  an  autopsy. 

In  Ashwell's  work  will  be  found  recorded  several  of  the 
most  interesting  cases  of  retroversion  of  the  gravid  uterus 
which  have  been  observed  since  William  Hunter's  case,  in- 
cluding some  noted  by  himself.  •  These  cases  made  evident 
the  great  importance  of  the  retention  of  urine  and  faeces  as 
clinical  features  of  such  cases;  for  death  was  usually  found 
to  occur  either  from  irritation,  by  inflammation  involving 
the  peritoneum,  or  by  rupture  of  the  bladder.  Great  relief 
always  occurred  when  the  bladder  could  be  emptied,  and 
in  some  cases,  when  the  disease  was  detected  early,  rectifi- 
cation of  the  uterus  followed  the  careful  daily  evacuation 
of  the  bladder.  On  the  other  hand,  evacuation  of  the 
bladder,  when  effected,  did  not  always  ensure  the  possibility 
of  reduction  of  the  displacement.  Thus  in  one  case  (Mr. 
Wilmer's)  the  bladder  was  relieved,  but  death  soon  occurred, 
and  the  uterus  was  found  so  firmly  wedged  in  the  pelvis 
after  death  that  it  could  not  be  raised  up  till  the  symphysis 
pubis  had  been  sawn  away.  In  Dr.  Ashwell's  time  he  found 
reason  to  blame  the  little  importance  attached  by  author- 
ities to  replacing  the  uterus,  and  he  forcibly  directs  at- 
tention to  the  advisability  of  reducing  the  displacement, 
and  at  as  early  a  period  as  possible.  He  also  gives  direc- 
tions for  accomplishing  it  which  we  have  hardly  improved 
upon  since  his  time.  Ashwell  used  and  recommended 
careful  pressure  upward,  the  patient  being  in  the  knee-and- 
elbow  position. 

The  pressure  was  to  be  made  by  the  fingers  in  the 
vagina  or,  if  that  plan  did  not  answer,  in  the  rectum. 
Dcnman,  followed  by  Blundell,  also  employed  the  knee- 
and-elbow  position,  and  speaks  of  it  as  sufficient,  if  kept  up 
sufficiently  long  to  procure  the  reduction  of  the  uterus, 
provided  that  the  bladder  be  kept  empt)'.  But  Ashwell 
disbelieved  the  efficacy  of  this  positional  treatment  alone 
in  severe  cases. 

As  to  the  difficulty  in  introducing  the  catheter  sometimes 


PREGNANCY   WITH   FLEXIONS   OF  THE   UTERUS.    375 

found  to  occur,  Ashwell  states  that  a  long  flexible  male 
catheter  can  always  be  employed  without  delay  or  suffer- 
ing. Should  it  be  impossible  to  use  the  catheter  the  supra- 
pubic puncture  of  the  bladder  is  required.  In  a  case  re- 
lated by  Ashwell  eleven  pints  of  ammoniacal  urine  was 
obtained  by  a  long  catheter,  the  uterus  was  reduced,  but 
abortion  and  death  in  five  days  followed. 

An  interesting  paper  by  the  late  Dr.  Phillips  is  recorded 
in  vol.  xiv.  of  the  "Obstetrical  Transactions,"  "On  Retro- 
flexion of  the  Uterus  as  a  frequent  cause  of  Abortion." 
Dr.  Gervis  also  communicated  some  most  instructive  cases 
to  the  Obstetrical  Society,  recorded  in  vol.  xvi.  of  the  "  Ob- 
stetrical Transactions."  The  discussion  which  followed  the 
reading  of  these  papers  may  be  consulted  with  advantage. 

The  dislocation  is  primary  or  secondary.  Formerly  it 
appears  to  have  been  taken  for  granted  that  it  was  always 
a  primary  affection.  The  late  Dr.  Tyler  Smith  was  one  of 
the  first  to  point  out  that  the  flexion  frequently  precedes 
the  pregnancy.  It  is  now  well  known  that  this  view  is  ac- 
curate so  far  as  a  large  majority  of  cases  is  concerned.  But, 
on  the  other  hand,  tlie  dislocation  is  also  undoubtedly  pri- 
mary in  some  few  instances. 

In  the  chapter  on  Retroflexion  of  the  Uterus  some  ac- 
count has  been  given  of  the  frequency  with  which  abortions 
occur  in  cases  of  this  disease. 

I.  Castas  in  which  Flexion  precedes  the  PregJiancy. — Tlie 
natural  history  of  cases  when  pregnancy  occurs  in  a  case  of 
retroflexion  is  as  follows:  Pain  is  usually  felt  more  or  less 
from  the  commencement,  or  there  is  at  all  events  a  sense  of 
discomfort,  bearing  down  and  weight,  and  inability  to  move 
without  producing  pain.  Difficulty  in  defaecation,  due  to 
the  pressure  of  the  body  of  the  uterus  on  the  rectum,  is 
commonly  observed.  Nausea,  sometimes  to  a  most  dis- 
tressing extent,  is  commonly  present.  In  some  cases  it  is 
the  most  severe  of  all  the  symptoms.  (The  connection  of 
obstinate  vomiting  with  existence  of  retroflexion  of  the 
gravid  uterus  will  be  discussed  later  on.)  As  the  preg- 
nancy advances  these  symptoms  increase  in  severity,  and  it 
is  found  difficult  to  pass  urine,  the  bladder  is  liable  to  be- 
come distended,  and  there  is  retention.  In  not  a  few  cases, 
the  fact  tliat  the  patient  passes  urine  very  often  disguises 
the  real  nature  of  the  case  and  conceals  the  existence  of  re- 
tention. By  the  third  month,  the  uterus,  being  now  of  con- 
siderable size,  exercises  great  pressure  on  all  the  organs  and 


37^  DISEASES   OP  WOMEN. 

structures  near  it.  At  this  time,  or  before  this  time  in  a 
few  instances,  nature  shows  herself  equal  to  the  emergency 
and  the  uterus  rises  upward,  the  posterior  rotation  dimin- 
ishes, and  relief  of  the  symptoms  follows.  But  if  the  pa- 
tient be  not  thus  relieved  naturally,  and  if  its  true  nature  be 
not  understood,  one  of  two  events  results — either  (i)  the 
uterus  throws  off  the  ovum  and  abortion  occurs;  or  (2)  the 
uterus  continues  to  expand,  though  under  increasingly  un- 
favorable conditions.  The  whole  pelvis  is  occupied  by  the 
uterus.  The  cervix  is  tilted  high  up  above  the  symphysis 
pubis,  and  the  bladder  becomes  so  much  dilated  by  the  re- 
tained urine  that  it  may  reach  to  a  point  above  the  umbili- 
cus. All  the  symptoms  increase  in  intensity.  The  pressure 
is  exceedingly  painful,  labor-like  forcing  pains  are  experi- 
enced, the  rectum  is  impassable,  the  urine  escapes  in  drops 
onh',  the  ureters  probably  undergo  dilatation, and  the  pelves 
of  the  kidneys  also.  The  sickness  may  be  incessant,  the 
prostration  extreme,  the  pulse  quick  and  small,  and  irrita- 
bility alternating  with  great  exhaustion  (see  chapter  on 
Vomiting  of  Pregnancy).  When  this  latter  condition  of 
things  persists  up  to  the  fifth  month  death  may  result  from 
the  accumulation  of  evils  then  present:  there  is  fever,  quick 
pulse,  gradual  prostration,  uraemia  probably;  in  some  cases 
rupture  of  the  bladder  may  occur  and  destroy  the  patient. 
A  third  course  is  sometimes  observed:  the  uterus  continu- 
ing to  expand  sends  an  extension  upward  into  the  abdomen, 
and  does  in  fact  become  partly  an  abdominal  organ;  but  at 
the  same  time  the  part  within  the  pelvis  remains  there. 
The  uterus  thus  acquires  a  curiously  abnormial  shape;  and 
in  the  celebrated  case  related  by  Dr.  Oldham*  no  abortion 
occurred,  but  the  uterus  continued  to  retain  this  shape  until 
the  full  term  of  pregnancy  had  been  reached. 

Rectification  of  the  position,  as  already  remarked,  some- 
times occurs  naturally,  and  if  so,  it  generally  happens  before 
the  fourth  month  has  been  reached.  The  larger  the  uterus 
the  greater  the  difficulty  offered  to  the  elevation  of  the  now 
greatly  distended  organ,  owing  to  the  projection  of  the 
sacral  promontory.  It  seems  probable  that  the  great  dis- 
tension of  the  bladder  sometimes  operates  at  a  critical  mo- 
ment in  preventing  the  rectification.  The  rectification  may 
occur  suddenly  or  gradually. 

The  disturbance  of  the  functions  of  the  bladder  are  among 

*  "  Obst.  Tr.ins.,"  vol.  i. 


PREGNANCY   WITH   FLEXIONS   OF   THE   UTERUS,    m 

the  most  serious  of  the  effects  produced  by  retroflexion  of 
the  gravid  uterus.  The  distension  of  the  bladder  and  irri- 
tation of  its  mucous  membrane  sometimes  produce  actual 
exfoliation  of  the  lining,  and  even  when  this  does  not  occur 
the  lining  may  become  seriously  damaged.  The  whole  lin- 
ing has  in  some  cases  come  away  in  a  single  piece.  When 
the  condition  is  unrelieved  tlie  distension,  beginning  at  the 
bladder,  extends  up  the  ureters  and  affects  the  pelves  of  the 
kidneys,  in  some  cases  causing  fatal  arrest  of  the  kidney 
functions.  As  already  stated,  rupture  of  the  bladder  has 
occurred  in  some  cases. 

Certain  peculiarities  of  the  subsequent  history  require 
notice.  Thus,  it  frequently  happens  that  when  abortion 
occurs  the  abortion  is  an  incomplete  one,  the  foetus  being 
expelled  but  the  membranes  left  behind.  The  retort  shape 
of  the  uterus  favors  retention  of  the  thickened  bag  of  tlie 
ovum,  and  it  may  be  some  days  or  even  longer  before  it  is 
expelled.     Septicaemia  may  follow. 

Further  on  still,  the  condition  cf  the  uterus  is  liable  to  be 
rendered  worse  than  before.  The  uterus,  having  discharged 
its  contents,  but  being  considerably  enlarged  and  retaining 
its  flexed  condition,  the  process  of  involution  is  arrested 
and  much  additional  trouble  results;  so  that  a  retroflexed 
uterus  which  has  become  impregnated  and  has  thrown  off 
the  ovum  is  liable  to  become  even  more  flexed,  and  to  give 
rise  to  more  irritation  than  before.  We  sometimes  meet 
with  cases  where  there  have  been  a  succession  of  abortions 
from  this  cause,  the  uterus  becoming  finally  so  much  dis- 
torted that  pregnancy  ceases  to  be  possible. 

2.  The  Flexion  and  Displacement  occur  after  Pregnancy  has 
commenced. — An  accident,  such  as  a  fall,  or  lifting  a  heavy 
weight,  or  a  continuous  exertion  of  any  kind,  may  suddenly 
produce  retroflexion  of  the  gravid  uterus.  There  are  several 
well-recorded  cases  of  this  kind,  where  the  uterus  was  ap- 
parently in  a  sound  state  previously  and  was  evidently 
afterward  displaced.  And  the  displacement  may  occur  as 
late  as  the  fourth  month — possibly  even  a  little  later. 

Once  produced,  the  symptoms  and  course  of  the  affection 
are  similar  to  those  in  the  former  class  of  cases.  The  chief 
difference  is  that  the  symptoms  usually  set  in  with  abrupt- 
ness when  the  displacement  happens  after  pregnancy  has 
commenced. 

The  diagnosis  of  the  existence  of  retroflexion  of  the  gravid 
uterus  is  most  important,  for  very  serjf>"<:  results  may  fcl- 


378 


DISEASES   OF   WOMEN. 


low  from  its  being  overlooked.  The  diagnosis  is  not  diffi- 
cult if  a  proper  examination  be  made.  The  tilting  upward 
of  the  OS  uteri  behind  the  pubes,  the  difficulty  of  reaching 
it,  the  evident  displacement  of  the  bladder  upward,  are 
easily  recognizable  in  most  cases.  The  presence  of  a  large 
tumor  above  the  pubes  when  the  bladder  is  distended  is 
rather  misleading,  for  it  has  been  sometimes  taken  to  be 
the  normally  placed  gravid  uterus.     A  vaginal  examination 


is  imperative;  and  tlie  rounded  tumor  of  the  uterus  behind 
the  vagina,  reaching  down,  it  miglit  be,  close  to  the  vaginal 
outlet,  is  easy  to  appreciate  by  the  touch.  The  only  diffi- 
culty is  in  deciding  that  the  tumor  so  felt  behind  the  vagina 
is  really  the  uterus,  for  it  might  be  due  to  haematocele  or  to 
hardened  effusion,  the  result  of  pelvic  cellulitis,  or  possibly 
be  an  ovarian  cyst.  The  use  of  the  catheter  would,  of 
course,  clear  up  any  doubt  as  to  the  nature  of  the  abdom- 
inal swelling  felt  above  the  pubes.     It  is  to  be  remarked 

*Fig.   119  represents  the  gravid   uterus  in  a  state  of  retroflexion  at 
about  four  months  of  pregnancy. 


PREGNANCY   WITH   FLEXIONS   OF   THE    UTERUS.    379 

that  the  tumor  felt  behind  the  vagina  may  be  a  little  to 
one  side  of  the  middle  line,  but  when  the  pregnancy  is 
farther  advanced  it  is  median. 

The  treatment  is  not  difficult  when  the  malady  is  recog- 
nized at  an  early  date. 

Take,  for  instance,  the  case  of  a  patient  six  weeks  preg- 
nant, the  uterus  being  retroflexed.  Here  the  treatment  con- 
sists in  gradually  pushing  up  the  fundus  uteri  by  pressure 
from  behind,  or  aiding  its  ascent  by  positional  treatment 
alone.  If  the  retroflexion  is  not  of  long  standing,  posi- 
tional treatment — i.e.,  avoidance  of  sitting,  occasional  knee- 
and-chest  position — may  prove  sufficient.  Generally,  how- 
ever, it  is  best  to  insert  a  Hodge-shaped  pessary.  A  rather 
thick  pessary  of  the  Albert  Smith  type,  is  best  for  this  pur- 
pose. Such  an  instrument,  properly  fitted,  is  most  effica- 
cious. The  pessary  is  worn  till  the  middle  of  pregnancy, 
and  is  then  removed.  It  has  happened  in  my  experience 
many  times  that  patients  under  treatment  for  retroflexion 
liave  become  pregnant  while  wearing  a  pessary  of  this  kind. 
Under  such  circumstances  it  has  been  my  practice  not  to 
remove  the  pessary  until  about  the  middle  of  pregnancy. 

Taking  a  case  where  the  pregnancy  has  advanced  to 
three  months,  or  a  little  beyond  that  time,  the  patient  in  a 
condition  of  much  suffering,  and  the  nature  of  the  case 
only  for  the  first  time  recognized,  the  treatment  is  more 
difficult.  The  bladder  should  be  first  relieved,  and  the 
uterus  replaced  as  soon  as  the  circumstances  of  the  case 
render  it  possible.  Sometimes  it  is  found  practicable  to 
effect  the  reduction  at  once.  In  other  cases  the  uterus  has 
become  so  fixed  by  the  swollen  condition  of  the  tissues  ad- 
jacent, or  so  jammed  down  in  the  pelvis  by  the  actual  size 
of  the  uterus,  that,  without  exercising  a  good  deal  of  force, 
a  rapid  reduction  is  not  advisable,  or  even  possible.  In 
cases  where  the  condition  of  the  patient  has  become  a 
really  critical  one,  and  the  constitutional  and  other  symp- 
toms of  very  intense  character,  it  may  be  advisable  to  defer 
operative  reduction  for  twenty-four  hours  after  the  use  of 
the  catheter.  Indeed,  there  appears  to  be  danger  in  sud- 
denly removing  a  very  large  quantity  of  urine  from  the 
bladder  and  simultaneously  attempting  the  operation  of  re- 
duction of  the  uterus,  on  account  of  extreme  shock  liable 
to  be  produced. 

It  remains  to  be  pointed  out  how  the  reduction  is  to  be 
effected.     One  method  consists  in   placing  the  patient  in 


380  DISEASES   OF   WOMEN. 

tlie  knee-and-chest  position,  opening  the  vagina  by  the 
Sims  speculum,  and  allowing  air  thus  to  pass  into  the 
vagina.  Dr.  Munde  *  records  a  case  where  this  procedure 
succeeded  at  once  in  the  case  of  a  patient  eleven  weeks 
pregnant.  The  same  author  refers  to  a  case  where  Dr. 
Solger,of  Berlin, had  a  like  result  in  a  patient  four  months 
pregnant.  The  manoeuvre  is  one  first  suggested  by  Dr. 
Campbell,  of  Georgia,  for  reduction  of  retroversion  (non- 
gravid  condition).  This  method  would  probably  not  suc- 
ceed where  there  is  great  swelling  and  compression  of  the 
adjacent  tissues.  Another  method  consists  in  placing  the 
patient  in  the  same  position  (as  practiced  by  Denman  and 
Blundell),  and  then  exercising  pressure  on  the  uterus  from 
the  vagina  by  means  of  the  fingers;  or  the  pressure  may  be 
made  from  the  rectum  in  the  same  way.  A  sustained  pres- 
sure thus  made  has  generally  been  found  to  answer  ex- 
tremely well.  A  round  india-rubber  air  ball  introduced 
into  the  rectum  and  distended  with  air  offers  a  means  of 
producing  continuous  pressure  in  a  convenient  direction, 
and  it  is  a  method  which  has  also  been  found  successful. 
Unless  the  case  were  one  of  extreme  character,  one  or  other 
of  these  methods  could  be  adopted,  the  pressure  being 
graduated  according  to  circumstances.  If  too  much  force 
be  employed  there  is  a  risk  of  inducing  abortion.  In  the 
ver}'^  worst  cases,  the  patient  being  in  extremis,  and  the  case 
practically  untreated  previously,  it  would  be  best  to  evac- 
uate the  uterus  by  drawing  down  the  os  uteri  with  the 
finger,  breaking  the  membranes,  and  allowing  an  abortion 
to  occur. 

After  reduction  of  the  displacement  a  pessary  should  be 
introduced  to  prevent  possibility  of  recurrence,  the  pessary 
to  be  removed  at  mid-term  of  pregnancy.  Various  precau- 
tions are  requisite  in  the  treatment,  w-ithout  which  failure 
may  result.  The  horizontal  position  must  be  rigidly  main- 
tained in  most  cases  for  two  or  three  weeks  after  the  reduc- 
tion, and  it  will  be  a  help  to  direct  the  knee-and-chest  posi- 
tion to  be  employed  five  or  six  times  a  day  during  this 
time.  The  bowels  must  be  kept  in  good  order  by  daily 
enemata.  The  sitting  posture  is  the  worst  of  all;  a  little 
walking  is  far  less  objectionable.  As  regards  the  pessary 
to  be  worn,  it  is  sufficient  to  refer  the  reader  to  the  chapter 
on  Retroflexion    for  information.     It    is  best  to  employ  a 

*  "Am.  Obst.  Trans.,"  vol.  ix.,  p.   293. 


PREGNANCY   WITH   FLEXIONS   OF   THE    UTERUS.    38 1 

pessary  rather  thicker,  though  not  necessarily  larger,  than 
in  cases  where  the  uterus  is  in  a  non-gravid  state. 

We  have  not  yet  done  with  the  subject.  It  is  found  that 
when  pregnancy  is  over,  the  uterus  has  frequently  a  great 
tendency  to  return  to  the  retroflexed  state.  In  one  case 
some  time  ago  under  my  care,  the  displacement  returned 
no  less  than  three  times  after  three  successive  pregnancies. 
The  following  was  the  order  of  events:  retroflexion  with 
gravid  uterus,  treatment  by  pessary,  removal  at  mid-term, 
pregnancy  continuing  to  full  term;  uterus  found  returning 
to  retroflexed  condition  a  month  after  delivery,  insertion 
of  the  pessary,  pregnancy  recurring  during  the  wearing  of 
the  instrument,  removal  at  mid- term,  etc.  This  is  by  no 
means  a  solitary  case,  and  convej's  a  lesson  as  to  the  neces- 
sity for  precaution  in  the  subsequent  management  of  such 
cases. 

ANTEFLEXION    AND    ANTEVERSION    OF    THE    GRAVID    UTERUS. 

There  can  be  no  doubt  that  the  most  common  cause  of 
abortions  is  the  presence  of  anteflexion  of  the  uterus.  The 
result  of  observations  extending  over  many  years  has  at 
least  convinced  me  of  the  truth  of  this  statement.  That  it 
is  not  as  yet  a  matter  of  general  professional  belief  is  due 
to  the  fact  that  cases  of  anteflexion  of  the  non-gravid  uterus 
are  often  passed  over  and  not  recognized  as  such. 

The  following  is  a  very  characteristic  case  related  by 
Boivin  and  Duges:  * 

Anteflexion  at  the  Beginning  of  Pregnancy. — A  young  woman 
aet.  24,  third  pregnancy,  the  last  four  years  previously,  one 
only  at  full  term.  Supposed  now  to  be  in  second  or  third 
month.  In  a  few  weeks  the  os  descended  lower  than  usual. 
The  cervix  uteri  lay  on  internal  surface  of  coccyx.  There 
was  a  rounded  tumor  somewhat  larger  than  the  natural 
size  of  the  fundus  uteri,  and  painful  when  pressed,  situated 
between  the  anterior  parietes  of  the  vagina  and  the  blad- 
der. It  was  the  body  of  the  uterus  directed  horizontally 
forward  and  recurved  at  a  right  angle  upon  the  cervix;  a 
deep  sinus  into  which  the  top  of  the  finger  was  easily  in- 
serted answered  anteriorly  to  the  point  of  the  flexion.  This 
was  owing  to  a  firm  contraction  of  the  tissues;  for  upon 
pushing  the  body  of  the  uterus  the  cervix  was  raised  with 

*"  Diseases  of  the  Uterus"  (translated  by  Heming,  1834),  p.  no. 


382  DISEASES   OF   WOMEN. 

it.  The  cervix  not  at  all  congested,  but  longer  than  usual, 
labia  prominent,  especially  anterior,  and  its  orifice  open. 
In  a  few  weeks  pregnancy  no  longer  doubtful;  later  on  cer- 
vix found  higher  up,  the  body  of  uterus  stilT  inclined  on 
cervix;  intervening  fold  much  diminished.  No  doubt  the 
anteflexion  would  cease  as  cervix,  expanding,  became  short- 
ened. 

Equally  characteristic  is  the  following,  related  by  Ash- 
well:  * 

Anteflexion  in  Early  Pregnancy. — The  wife  of  a  medical 
man,  aet.  36,  in  first  month  of  pregnancy  fell  from  a  steep 
stair,  the  bowels  being  at  the  time  very  constipated.  No 
haemorrhage,  but  syncope  for  an  hour.  For  six  or  seven 
weeks  she  was  never  free  from  a  heavy  bearing-down  sen- 
sation in  front,  rendering  micturition  frequent  and  painful, 
defaecation  not  improved.  She  was  irritable  and  feverish. 
The  husband  thought  the  womb  was  retroverted.  At  the 
end  of  third  month  I  found  the  cervix  uteri  in  its  natural 
position,  but  not  so  the  fundus,  which,  in  the  form  of  a 
rounded  and  solid  tumor,  was  lying  forward  between  the 
anterior  wall  of  the  vagina  and  the  bladder.  She  com- 
plained of  pressure  at  the  part  when  the  body  was  curved. 
The  cervix  was  elongated,  fuller  and  harder  than  natural; 
the  OS  open.  I  placed  the  fingers  of  my  left  hand  behiml 
the  pubis,  endeavoring  in  this  way  to  reach  the  fundus, 
while  with  the  forefinger  of  my  right  hand  I  tried  to  draw 
the  cervix  downward  and  forward.  I  did  not  succeed,  and 
no  further  manual  efforts  were  made.  Care  was  taken  that 
she  observed  the  recumbent  position  for  a  month.  An  ex- 
amination at  the  sixth  month  satisfied  her  husband  that 
the  curvature  had  nearly  disappeared,  and  though  not  dur- 
ing the  pregnancy  ever  quite  free  from  suffering,  she  was 
delivered  without  difficulty  and  recovered  remarkably  well. 

There  are  two  classes  of  cases — (i)  those  in  which  the 
uterus  was  in  a  normal  condition  when  the  pregnancy  be- 
gan, and  (2)  those  in  which  the  uterus  was  anteflexed  be- 
fore the  pregnancy  commenced. 

I.  Anteflexion  occurring  after  Pregnancy  has  begun. — This 
is  not  so  common  a  condition  as  the  following  one,  but  it 
is  by  no  means  rare.  A  sudden  jerk,  or  blow,  or  fall,  or  a 
long-continued  exertion  of  any  kind,  may  displace  anteri- 
orly the  gravid  uterus.      An  accident  severe  enough  to  pro- 

*"  Diseases  of  Women"  (1S44),  p.  596. 


PREGNANCY   WITH   FLEXIONS   OF   THE    UTERUS.    383 

duce  such  a  result  very  frequently  has  the  further  result  of 
inducing  an  abortion;  but  in  some  instances  the  abortion 
does  not  happen  at  the  time;  the  patient  feels  ill,  and  as  the 
pregnancy  proceeds  becomes  worse,  and  very  possibly  an 
abortion  occurs  a  month  or  two  later,  or,  under  favorable 
circumstances,  pregnancy  ends  at  the  proper  time. 

2.  The  Antefiexion  precedes  the  Pregnancy. — When  the  ante- 
flexed  uterus  becomes  gravid,  it  frequently  happens  that  it 
is  able  to  expand,  and  to  rise  up  out  of  the  pelvis;  and  so 
the  pregnancy  proceeds,  at  first  with  more  or  less  difficulty, 
but  later  on  without  difficulty.  The  obstacle  to  the  eleva- 
tion of  the  uterus  in  process  of  expansion  is  less  than  in 
the  case  of  the  retroflexed  uterus.  Taking  indiscriminately 
one  hundred  cases  of  anteflexion  and  one  hundred  cases  of 
retroflexion  it  might  be  predicted  that  an  abortion  would 
certainly  occur  more  often  in  the  latter  class  of  cases  tiian 
in  the  former.  The  promontory  of  the  sacrum  hinders  re- 
duction of  the  retroflexed  gravid  uterus,  but  the  symphysis 
pubis  does  not  project  so  as  materially  to  interfere  with 
the  elevation  of  the  anteflexed  gravid  uterus.  Thus  abortion 
is  not  so  frequent  a  result  in  cases  of  anteflexion  as  in  cases 
of  retroflexion.  Yet  in  regard  to  absolute  frequency  of  abor- 
tions anteflexion  stands  before  retroflexion.  Absolute  in- 
carceration of  the  gravid  uterus  is  not,  for  the  reasons  just 
mentioned, so  liable  to  occur  in  anteflexion  as  it  is  in  retro- 
flexion. But  nevertheless  such  incarceration  does  some- 
times occur.  When  the  incarceration  occurs  it  is  more 
generally  for  a  limited  period  only,  the  uterus  either  (i)  ris- 
ing up  out  of  the  pelvis,  or  (2)  expelling  its  contents,  and  in 
either  case  the  patient  becomes  relieved.  Fatal  incarcera- 
tion, such  as  may  occur  in  retroflexion,  is  very  rare.  Ulrich, 
however,  records  a  remarkable  instance  of  it.  The  case 
will  be  given  in  full  in  the  chapter  on  the  Vomiting  of 
Pregnancy.  In  this  case  the  condition  was  recognized 
during  life,  but  the  attempts  at  alteration  of  the  position 
of  the  uterus  failed.  The  uterus  lay  in  this  case  obliquely 
across  the  pelvis.  This  oblique  position  appears  liable  to 
occur  as  the  pregnancy  proceeds,  seeing  that  the  oblique 
diameter  is  longer  than  the  antero-posterior,  and  there  is 
more  room,  therefore,  in  the  oblique  position. 

The  history  of  many  cases  is  as  follows:  The  uterus  is 
anteflexed  in  the  first  or  second  degree,  with  first  degree 
of  anterior  rotation.  Pregnancy  occurs.  An  unusual  de- 
gree of  nausea   is  observed  almost  from  the  moment  preg- 


384  DISEASES   OF   WOMEN. 

nancy  begins.  There  is  great  frequency  of  micturiilon. 
Walking  and  sitting  aggravate  both  of  the  latter  symptoms. 
The  patient  is  more  or  less  uncomfortable  in  other  respects. 
This  condition  persists  up  to  the  middle  of  the  third  month. 
Then  the  symptoms  undergo  a  change — either  improve,  or 
become  very  much  worse.  If  they  improve,  that  indicates 
that  the  bend  in  the  uterus  has  given  way,  the  organ  is 
expanding  more  easily,  and  rising  up  out  of  the  pelvis.  If, 
on  the  contrar}',  there  is  intensification  of  the  symptoms, 
this  means  that  incarceration  is  present.  The  incarceration 
is  perhaps  only  temporary;  at  the  end  of  a  few  days  the 
expansion  does  the  work  required  and  the  uterus  rises  xip- 
ward. 

In  another  set  of  cases  the  history  is  as  follows:  The 
uterus  has  been  anteflexed  for  some  time.  It  is  hard, 
rigid,  and  firm  in  texture.  Pregnancy  occurs.  Instantly 
great  pain  is  felt;  nausea  is  very  troublesome,  so  also  fre- 
quent micturition.  The  patient  continues  to  go  about;  the 
uterus  is  not  kept  at  rest;  at  the  end  of  about  two  months 
abortion  occurs. 

In  some  cases  the  patient  loses  blood  from  time  to  time, 
the  indication  often  of  impending  abortion,  but  not  of 
course  necessarily  so. 

The  difficulty  in  cases  such  as  above  described  arises 
from  three  sources — (i)  The  hardened,  contracted  condition 
of  the  uterine  tissues  (in  chronic  cases).  (2)  The  down- 
ward pressure  of  the  abdominal  viscera.  When  these  two 
difficulties  are  conjoined  the  result  is  more  likely  to  be  un- 
favorable. Experience  shows  that  while  in  many  cases  re- 
moval of  the  latter  source  of  difficulty  by  keeping  the 
patient  in  the  horizontal  posture  is  successful  in  averting 
an  impending  miscarriage,  there  are  others  in  which  this 
precaution  alone  is  insuflficient.  (3)  A  further  source  of 
difficulty  in  some  cases  is  the  cedematous  effusion  surround- 
ing the  uterus. 

I  first  became  aware  of  the  importance  of  this  subject 
about  eighteen  years  ago.  A  lady  who  had  been  .treated 
by  me  previously  for  anterior  displacement  became  preg- 
nant, and  soon  after  the  beginning  of  the  third  month 
presented  all  the  symptoms  above  described.  The  uterus 
was  incarcerated  in  the  pelvis,  there  was  considerable 
cedematous  swelling  of  parts  surrounding  the  vulva,  and 
the  uterus  was  jammed  downward  behind  the  symphysis 
pubis.     The    horizontal  position,  kept  up  for  a  week  or 


PREGNANCY   WITH   FLEXIONS   OF   THE    UTERUS.    3S5 

ten  days,  relieved  the  symptoms,  and  pregnancy  proceeded 
to  about  eight  months  when  the  patient  was  delivered  of  a 

Fig.  120.* 


dead  child.     Since  then  I  have  seen   many  such  cases,  and 
have  become  impressed  with  the  conviction  of  the  extreme 


*  Fig.  120  represents  anteflexion  of  the  gravid  uterus  at  about  the  fourth 
»nonth  of  pregnancy. 


386  DISEASES   or  '\VOMEN< 

importance  of  anteflexion  as  a  cause  of  abortion,  and 
liave  obtained  valuable  information  as  to  the  means  of 
preventing  it. 

DIAGNOSIS. 

This  presents  little  difficulty.  The  patient  is  usually 
known  to  be  pregnant.  The  pain  and  distress,  together 
with  the  nausea,  announce  that  pregnancy  is  not  proceed- 
ing normally.  Unless  an  examination  be  made,  it  is  diffi- 
cult to  say  whether  retroflexion  or  anteflexion  be  present. 
The  position  of  the  os  uteri,  which  is  very  far  back,  and  the 
presence  of  a  dense  resisting  tumor  (the  anteflexed  body 
of  the  uterus)  felt  through  the  vaginal  roof,  indicate  the 
nature  of  the  case.  The  uterine  tumor  is  rounded,  elastic, 
generally  symmetrical,  and  usually  in  the  middle  line;  but 
as  the  uterus  increases  in  size  it  comes  to  occupy  an  oblique 
position  in  one  of  the  oblique  diameters  in  the  pelvis. 
This  oblique  position  was  present  in  Ulrich's  fatal  case,  and 
I  have  observed  it  in  two  cases.  A  case  of  extra-uterine 
pregnancy  might  present  somewhat  similar  symptoms,  but 
the  tumor  enclosing  the  foetus  would  be  probably  unilateral. 
It  must  be  recollected  that  in  ordinary  normal  pregnancy 
the  uterine  body  would  be,  say  at  the  end  of  two  months, 
rather  readily  felt  by  the  exploring  finger  through  the 
vaginal  roof,  but  it  should  not  of  course  be  jammed  down- 
ward behind  and  close  to  the  symphysis  pubis.  There  is  a 
perceptible  interval  between  the  uterus  and  the  pubic  bones 
when  the  gravid  uterus  is  in  a  normal  state  at  the  end  of 
two  months. 

In  the  chapter  on  Anteflexion  and  Anteversion  statistics 
are  given  as  to  the  frequency  of  abortions  due  to  this  con- 
dition of  the  uterus.  The  repetition  of  abortions  is  a  notable 
feature — thus  four  or  five  times  in  succession  the  abortion 
may  occur.  The  success  in  arresting  the  occurrence  of 
abortion  by  treating  the  anteflexion  is  one  of  the  man}-  argu- 
ments adducible  in  favor  of  the  above  views. 

A  most  interesting  feature  in  cases  of  anteflexion  with 
pregnancy  is  the  great  frequency  of  obstinate  nausea 
under  these  circumstances.  It  may  be  predicted,  almost 
with  certainty,  that  if  a  patient  affected  with  anteflexion 
becomes  pregnant  she  will  suffer  severely  from  nausea 
during  the  early  part  of  the  pregnancy.  We  now  and  then 
meet  with  cases  when  the  patient  is  suffering  from  what  is 


PREGXAXCV    WITH    FLEXIONS   OF  THE   UTERUS.    387 

termed  uncontrollable  vomiting  in  pregnancy.  These  are 
generally  cases  of  the  kind  liere  alluded  to — viz.,  cases  of 
severe  anteflexion  associated  with  pregnancy.  Not  always 
of  anteflexion,  because  in  some  cases  there  is  retroflexion; 
but  practically  it  may  be  said  that  anteflexion  is  chiefly  re- 
sponsible for  these  cases  of  severe  vomiting. 

The  special  significance  of  nausea  in  relation  to  preg- 
nancy will  be  found  fully  discussed  in  the  following  chap- 
ter. 

It  may  be  mentioned  that  another  result  connected  with 

Fig.  121.* 


abortion  is  the  reteniioii  of  the  ovum  in  the  uterus  after  its 
death.  For  instance,  a  patient  has  a  miscarriage  due  to 
anteflexion:  the  ovum  dies  and  the  patient  loses  perhaps  a 
great  quantity  of  blood.  In  a  certain  number  of  these 
cases  the  ovum  will  remain  in  the  uterus  a  considerable 
number  of  days,  and  the  reason  it  does  not  come  away  is 
that  the  shape  of  the  canal  prevents  it.  Unless  properly 
assisted,  there  occurs  a  considerable  delay  in  its  escape  from 
the  uterus.  The  difficulty  results  from  the  acutely  flexed 
state  of  the  organ,  and  the  knowledge  of  this  fact  is  the 
secret  of  success  in  the  treatment  of  such  cases  of  retention 


*  Fig   121  represents  the  condition  of  the  uterus  when  distended  by  a 
retained  ovum  or  clots  in  a  case  of  anteflexion. 


388  DISEASES   OF  WOMEN. 

of  the  ovum.  The  cavity  of  the  uterus  may  become  cort- 
siderably  distended  by  blood  or  clots,  as  shown  in  the  an- 
nexed figure  (Fig.  i2i).  In  these  cases  of  miscarriage,  if 
the  ovum  is  retained,  a  frequent  result  is  that  it  becomes 
putrid,  and  gives  rise  to  an  offensive  discharge  which  may 
continue  for  some  time.  When,  however,  the  uterus  is 
artificially  straightened,  the  ovum  is  generally  easily  evacu- 
ated, and  the  offensive  discharge  ceases.  Such  retention  of 
part  of  the  ovum  may  occur  equally  in  anteflexion  and 
retroflexion  of  the  gravid  uterus.  With  reference  to  the  im- 
portance of  this  relation  subsisting  between  retention  of 
the  ovum  in  early  miscarriages,  and  flexions,  I  do  not  hesi- 
tate to  say  that,  since  my  attention  has  been  directed  to  the 
mechanism  of  these  occurrences,  I  have  not  seen  a  case  in 
which  the  relation  described  has  not  been  most  obvious. 
The  difficulty  in  relieving  the  patient  and  putting  an  end 
to  her  various  discomforts  has  ceased  on  taking  measures 
to  straighten  the  canal,  and  thus  allowing  the  uterus  to 
exert  advantageously  the  proper  expulsive  action  on  its 
contents. 

TREATMENT. 

In  simple  cases,  where  the  symptoms  are  not  severe  and 
the  patient  has  not  had  an  abortion,  the  following  treat- 
ment will  probably  prove  sufficient:  The  patient  should  be 
instructed  to  avoid  all  severe  exertion  until  after  the  end 
of  the  fourth  month;  she  should  avoid  the  sitting  position 
whenever  practicable;  carriage  exercise  only  in  the  recum- 
bent position;  short  walks  to  be  preferred;  as  a  rule,  the 
patient  to  use  a  chair  with  a  very  sloping  back,  or  the  sofa; 
nothing  tight  to  be  worn  over  the  abdomen;  and  the  bowels 
to  be  carefully  regulated,  so  as  to  avoid  any  straining  effort. 

In  more  severe  cases  the  patient  must  at  once  take  to  her 
bed  in  order  to  have  the  advantage  of  perfect  rest  in  the 
horizontal  position.  If  relief  of  the  symptoms  does  not 
follow  very  speedily — i.e.,  within  a  day  or  two — it  may  be 
necessary  to  assist  the  elevation  of  the  body  of  the  uterus. 
This  may  be  done  best  by  inserting  a  small  air-ball  pessary 
about  one  and  three  quarter  inches  in  diameter  into  the 
vagina,  and  inflating  it  to  two  inches  with  air.  This  may 
be  left  in  situ  for  twenty-four  hours,  and  then  removed  and 
reapplied  if  necessary.  To  aid  in  the  elevation  of  the 
uterus  a  pillow  may  be  placed  under  the  pelvis  for  an  hour 


PREGNANCY   WITH   FLEXIONS   OF  THE   UTERUS.    389 

at  a  time,  the  head  being  only  slightly  raised.  I  have  fre- 
quently employed  a  cradle  pessary  in  severe  cases  of  ante- 
flexion of  the  gravid  uterus,  removing  it  when  pregnancy 
has  reached  the  end  of  the  fourth  month.  In  several  cases, 
this  instrument  having  been  used  to  remedy  the  anteflexion, 
the  patient  has  continued  to  wear  it  uninterruptedly  up  to 
the  end  of  the  fourth  month;  but  I  do  not  recommend  that, 
in  such  cases,  the  cradle  pessary  should  be  employed  in  a 
haphazard  way,  or  by  any  one  not  accustomed  to  its  use. 

I  regard  the  positional  treatment  above  described  as 
quite  essential  in  such  cases.  A  remarkable  proof  of  the 
adequacy  of  the  explanation  of  the  occurrence  of  severe 
sickness  in  pregnancy  is  afforded  by  the  success  of  this 
positional  treatment  in  relieving  the  patient:  for  I  have 
records  of  many  cases  where  the  sickness  has  been  relieved 
almost  at  once  by  mere  positional  treatment  alone. 

The  very  severe  class  of  cases  remains  to  be  considered — 
that,  namely,  in  which  the  condition  of  the  patient  is  criti- 
cal owing  to  long-continued  and  irrepressible  vomiting. 
These  cases  present  themselves  almost  (but  not  quite) 
without  exception  just  before  the  mid-period  of  pregnancy. 
It  is  in  this  class  of  cases  that  it  has  been  thought  right  to 
advise  the  induction  of  abortion  in  order  to  save  the  pa- 
tient's life.  The  late  Dr.  Copeman  of  Norwich,  a  few  years 
ago  found  that  by  dilating  the  cervical  canal  of  the  uterus 
the  nausea  is  arrested.  He  had  dilated  the  cervix  as  pre- 
paratory to  the  evacuation  of  the  uterus;  but  the  day  after 
the  dilatation,  as  the  nausea  had  disappeared,  it  was  not 
necessar}'  to  complete  the  process,  and  the  patient  had  no 
more  sickness.  He  repeated  the  operation  in  other  instances 
with  a  like  result — finding  thus,  as  he  believed,  an  im- 
portant and  valuable  means  of  arresting  the  vomiting  in 
these  dangerous  cases.  A  more  particular  account  of  these 
cases  and  of  the  deductions  to  be  drawn  from  them  will  be 
found  in  the  succeeding  chapter. 

A  perusal  of  the  particulars  of  his  cases  will,  I  believe, 
sustain  the  belief  that  they  were  cases  of  anteflexion  of 
the  uterus,  coupled  in  some  instances  with  very  marked 
rigidity  of  the  cervix,  and  great  resistance  and  firmness 
of  the  structures  around  the  internal  os  uteri;  in  other 
words,  that  the  uterus  was  either  markedly  anteflexed, 
or  that  there  was  hypertrophy  and  contraction,  the  result 
of  pre-existing  flexion  of  the  uterus. 

The  success  of  the  procedure,  which   Dr.  Copeman  him^ 


390  DISEASES   OF  WOMEN. 

self  did  not  attempt  to  explain,  is  to  be  accounted  for  as 
follows:  (i)  These  are  cases,  usually,  of  anteflexion,  the  os 
is  far  back,  the  body  of  the  uterus  low  down  behind  the 
symphysis.  Now  it  is  impossible  to  introduce  the  finger — 
indeed,  any  dilating  agent — into  the  cervical  canal  without 
drawing  forward  the  os  uteri;  equally  impossible  to  draw 
the  OS  uteri  forward  without  at  the  same  time  dislodging 
the  uterus  from  its  abnormal  position;  in  other  words,  the 
procedure  of  dilatation  of  the  cervix  had  as  one  of  its  re- 
sults the  rectification  of  the  position  of  the  uterus.  (2)  The 
actual  dilatation  of  the  cervix  uteri.  This  dilatation,  in 
cases  where  the  cervix  is  contracted  and  hardened  by  pre- 
vious disease,  releases  the  tension  of  the  parts,  and,  in  fact, 
it  does  artificially  what  the  uterus  has  been  vainly  trying 
to  do  before  for  itself.  Experience  has  shown  that  this  con- 
dition of  things  is  liable  to  be  met  with  in  certain  cases, 
and  they  will  probably  be  almost  invariably  found  to  be 
cases  where  there  has  been  marked  flexion  of  the  uterus 
previously,  and  generally  cases  in  which  there  have  been 
previous  pregnancies. 

Two  kinds  of  difficulty  may  be  met  with  in  cases  of  ante- 
flexion of  the  gravid  uterus:  (i)  The  position  of  the  uterus 
cannot  be  rectified,  or  (2)  the  cervix  is  very  hard  and  con- 
densed, and  hypertrophied.  The  two  difficulties  may  be 
met  with  in  conjunction  or  separate.  When  the  condition 
of  the  patient  is  a  critical  one,  it  may  be  assumed  that  one 
or  both  of  the  difficulties  described  exists,  and  requires 
mechanical  assistance. 

1.  As  regards  the  liberation  of  the  uterus.  Carefully 
applied  pressure  will  hardly  ever  fail  in  elevating  the  uterus, 
and  in  cases  where  this  is  impossible  the  method  of  pres- 
sure by  use  of  an  elastic,  air,  or  water  pessary  in  the  vagina 
may  be  tried.  It  is  to  be  expected  that,  in  some  cases,  one 
or  two  days  or  more  might  be  required  to  effect  the  reduc- 
tion, the  pressure  being  gradually  increased  from  time  to 
time. 

2.  Concurrently  with  the  rectification  of  position  of  the 
uterus,  or  separately,  or  subsequenth^  as  circumstances 
might  indicate,  the  dilatation  of  the  cervix  may  require  to 

*be  performed.  The  best  means  of  accomplishing  it  will  be 
described  in  the  next  chapter  on  the  Treatment  of  the 
Vomiting  of  Pregnancy. 

I  have  in  my  own  practice  only  had  occasion  to  use  dila- 
tation of  the  cervix  once  in  a  case  where  rectification  pure 


THE  VOMITING   OF   PREGNANCY.  39I 

Riid  simple  failed  in  relieving  the  nausea.  In  this  case 
the  uterus  was  exceeelingly  hard  and  almost  cartilaginous, 
and  the  nausea  persisted  in  spite  of  rectification  of  the 
anteflexion.  In  this  case  I  adopted  the  dilatation  method 
of  Dr.  Copeman  and  found  the  tissues  around  the  internal 
OS  very  unyielding,  and  the  dilatation  was  effected  with  the 
greatest  difficulty.  The  nausea  became  relieved,  but  abor- 
tion followed  in  this  instance. 

SUBSEQUENT    TREATMENT. 

When  abortion  has  occurred  in  consequence  of  anteflex- 
ion of  the  uterus,  the  malady  is  likely  to  become  much 
exaggerated  afterward,  unless  care  be  taken  to  prevent  it. 
Tlie  patient  must  be  kept  in  the  horizontal  position  for 
some  days  after  the  abortion  and  means  taken  to  promote 
tlie  involution  of  the  uterus  in  a  proper  manner.  If  no 
care  be  taken,  the  uterus  is  very  apt  to  settle  down,  as  it 
hardens  and  contracts,  into  a  condition  of  flexion  even 
worse  than  existed  before;  and  a  repetition  of  abortions 
produces  chronic  hypertrophy  and  exaggeration  of  flexion, 
and  the  other  usual  effects  of  these  complications.  A  few 
days  after  tlie  abortion  is  over,  and  before  tiie  uterus  has 
firmly  contracted,  is  an  excellent  opportunity  for  moulding 
the  organ  into  a  better  shape,  and  at  that  time  a  pessary 
may  often  be  employed  wtth  great  advantage. 


CHAPTER   XXVIII. 

THE    VOMITING    OF    PREGNANCY. 

Author's  Explanation,  and  Paper  on  Subject  in  1871. 

Severe  or  Dangerous  Vomiting  in  Pregnancy. — Historical  and  Criti- 
cal Inquiry  into  the  Subject,  with  Summary  of  Observations  recorded 
by  Others — Account  of  Cases  published — Dr.  Copeman's  Cases:  Ex- 
planation of  these — Cases  observed  by  the  Author — Aubert's  Observa- 
tions on  Influence  of  Movements  of  Uterus  in  producing  Nausea — 
General  Rhume  of  the  Subject. 

Treat.ment  of  the  Vomiting  of  Pregnancy. 

The  subject  discussed  in  the  present  chapter  is  one  which 
more  usually  finds  a  place  in  works  on  the  subject  of  mid- 
wifery, but  the  close  connection  which  appears  to  subsist 
between  the  presence  of  distortion  of  the  uterus  and  the 


39^  DISEASES   OF  WOMEN. 

occurrence  of  severe  vomiting  in  pregnancy  renders  it  de- 
sirable to  discuss  the  question  as  a  sequel  to  the  preceding 
chapter,  wherein  the  association  of  flexions  of  the  uterus 
with  pregnancy  has  been  considered. 

In  a  paper  presented  to  the  Obstetrical  Society  of  Lon- 
don, 187 1,*  I  ventured  to  offer  an  explanation  of  the  cause 
of  the  vomiting  of  pregnane)'. 

Nausea  and  vomiting  are  associated  with  pregnancy. 
Nausea  and  vomiting  are  associated  with  disease  of  the 
uterus.  Both  these  propositions  are  true  But  nausea  and 
vomiting  are  not  akvays  present  in  cases  of  pregnancy,  nor 
are  these  symptoms  always  present  in  cases  of  uterine 
disease. 

Looking  at  the  question  from  a  broad  point  of  view,  it  is 
quite  evident  that  the  condition  (whatever  that  ma}'  be) 
which  gives  rise  to  nausea  and  vomiting  in  uterine  disease 
is  possibly  the  cause  of  it  in  pregnancy. 

Unquestionably,  the  occasional  obstinacy  of  the  symptom 
is  equally  observed  in  pregnancy  and  uterine  disease.  An 
attentive  comparison  of  the  phenomena  witnessed  in  the  two, 
and  a  close  scrutin}'  of  clinical  facts,  mutually  throw  light 
the  one  on  the  other. 

Having  frequently  observed  severe  sickness  in  cases  of 
flexion  of  the  non-gravid  uterus,  and  observing  the  occur- 
rence of  marked  sickness  during  pregnancy  in  the  same 
cases,  I  was  led  to  the  conclusion  that  the  flexion  of  the 
uterus  is  the  condition  which  gives  rise  to  the  severe  sick- 
ness in  both  conditions.  Carefully  testing  the  accuracy  of 
this  conclusion  by  observation  of  cases  I  was  induced  to 
frame  the  theory  that  the  sickness  of  pregnancy  is  due  to 
the  combined  effects  of  the  increasing  distension  of  the 
uterus  and  an  associated  flexion  of  the  organ.  Facts  led 
me  to  the  conclusion  that  in  cases  of  flexion  it  is  the  com- 
pression undergone  by  the  uterine  tissues  (markedly  by 
the  nerve-fibres)  at  the  seat  of  the  flexion  which  is  the  cause 
of  the  nausea  and  sickness,  both  in  the  gravid  and  in  the 
non-gravid  state. 

The  patient  generally  experiences  the  symptom  in  ques- 
tion on  first  rising  in  bed  in  the  morning,  or  while  dressing. 
Why  is  this  ?  Is  it  not  because  the  body  of  the  uterus  falls 
a  little  downward  in  obedience  to  the  law  of  gravity,  thereby 

*  "  Obst.  Trans."  vol.  xiii. :  "The  Vomiting  of  Pregnancy:  its  Causes 
and  Treatment." 


THE   VOMITING   OF    PREGNANXY.  393 

producing  a  slight  flexion  and  a  compression  of  uterine 
tissues  at  the  seat  of  the  flexion?  During  the  first  three 
and  a  half  months  the  temporary  flexion  is  possible,  because 
the  uterus  is  still  in  the  pelvis.  Generally,  after  tliat  time 
it  rises  out  of  the  pelvis,  and  flexion  decreases  with  the  de- 
crease of  nausea.  Is  it  not  the  fact  that,  for  the  most  part, 
the  liability  to  nausea  and  vomiting  ceases  at  precisely  this 
period  ?  It  is  also  a  fact,  which  will  be  confirmed  by  all 
who  make  the  experiment,  that,  in  ordinary  slight  cases  of 
nausea  and  vomiting,  by  ordering  the  patient  to  remain 
absolutely  in  the  horizontal  posture  the  disturbance  ceases. 

Since  the  publication  of  my  original  paper  in  1S71  the 
subject  has  much  occupied  my  attention,  and  many  new 
facts  have  been  recorded  by  various  observers.  I  propose 
now  to  consider  the  subject  as  it  stands  at  the  present  time, 
giving  an  account  of  the  principal  recorded  facts  bearing 
on  the  subject. 

The  principal  interest  attaches  to  those  cases  in  which 
the  vomiting  seriously  endangers  life  ;  and  it  is  therefore 
desirable  that  the  facts  relating  to  such  cases  should  be 
carefully  considered. 

SEVERE    OR    DANGEROUS    VOMITING    IN    PREGNANCY. 

A  tendency  to  nausea  and  vomiting  have  been  from  time 
immemorial  associated  with  the  existence  of  pregnancy — 
so  much  so,  indeed,  that  the  presence  of  nausea  and  sick- 
ness have  come  to  be  regarded  as  a  sign  of  the  existence  of 
pregnancy.  In  a  mild  form  nausea  and  vomiting  are  rather 
common  in  the  early  months  of  pregnancy  ;  but  as  many 
cases  occur  in  which  the  symptom  is  absolutely  wanting,  it 
cannot  be  regarded  as  essential  to  pregnancy.  As  a  rule, 
the  degree  of  nausea  or  vomiting  observed  is  not  severe, 
only  producing  inconvenience  ;  but  in  a  few  cases  it  is  ex- 
ceedingly severe,  and  becomes  dangerous,  (i)  because  of 
the  exhausting  effect  of  the  repeated  efforts  of  vomiting, 
and  (2),  because  of  the  starvation  it  produces.  The  dan- 
gerous cases  are  those  in  which  the  vomiting  is  uncontroll- 
able, and  in  which  it  continues  for  weeks  or  months. 

While,  therefore,  as  a  rule  the  sickness  of  pregnancy  is 
not  a  matter  calling  for  serious  attention,  the  exceptional 
cases  just  alluded  to,  where  the  malady  is  so  serious  as  to 
imperil  life,  have  been  the  subject  of  much  attention  ;  for 
in  not  a  few  instances  death  has  actually  occurred  as  the 
result  of  severe  uncontrollable  vomiting  in  pregnancy. 


394  DISEASES   OF   WOMEN. 

Respecting  the  very  severe  cases  of  vomiting  in  preg- 
nancy, it  is  necessary  to  state,  in  the  first  instance,  that  in 
the  large  majority  of  cases  the  records  of  autopsies  have 
thrown  but  little  light  on  the  cause  of  the  excessive  vomit- 
ing which  destroyed  the  patient.  In  some  rare  instances 
lesions  of  other  organs  have  been  encountered,  presumably 
in  some  measure  explaining  the  sickness  ;  in  some  cases 
the  uterus  was  in  an  abnormal  condition  ;  but  in  the  large 
majority  of  instances  no  lesion  of  any  kind  was  found. 

A  good  account  of  the  published  literature  of  the  subject 
was  given  by  Anquetin  in  the  year  1865.*  More  recently  f 
Dr.  McClintock  has  written  an  essay  summarizing  the  prin- 
cipal known  facts  relating  to  the  subject. 

I.  It  has  been  shown  that  in  some  of  the  few  fatal  cases 
in  which  autopsies  have  been  made  the  fatal  nausea  was 
probably  due  to  lesion  of  some  other  organ  t/iafi  the  uterus. 

Under  this  head  may  be  mentioned — a  case  recorded  by 
Valleix  where  chronic  gastritis  was  found  to  be  present 
(Query — Was  the  gastritis  the  result  of  the  vomiting?)  ;  a 
case  by  Taurin,  of  redness  and  softening  of  the  stomach  ; 
cases  by  Dubois,  Chomel,  and  Sandras,  of  similar  character  ; 
a  case  by  Depaul,  where  cancer  of  the  pylorus  was  found 
post  mortem  j  a  case  by  Pipelet,  of  epigastric  hernia  ;  a  case 
by  Lanceraux,  where  Coesarean  section  was  performed,  and 
after  death  atrophy  of  the  muscular  system  and  of  cellulo- 
adipose  tissues  was  found  to  exist  ;  a  case  by  Trousseau, 
where  scirrhous  induration  near  pylorus  was  found  after 
death  ;  a  case  by  Schutbach,  where  a  tumor  the  size  of  an 
^ZZy  near  the  pylorus,  was  found  in  a  state  of  ulceration 
after  death  (these  cases  are  quoted  by  Anquetin).  In  addi- 
tion to  the  foregoing,  Anquetin  mentions  cases  of  tubercle 
of  lungs  (Schilachigla),  tubercle  of  brain  (Rayer  and  De- 
paul), alterations  of  mesenteric  glands  (Sandras),  of  glands 
of  epigastrium  (Blot),  fatty  degeneration  of  liver  (Chomel), 
biliary  calculi  (Taurin),  redness  of  semilunar  ganglia  of 
solar  plexus  (Lobstein),  congestion  of  meninges  (Sandras). 
Burns  J  gives  a  case  where  a  biliary  calculus  was  found  to 
be  impacted.  Robert  Lee  §  gives  a  case  where  bronchitis 
and  fever  had  occurred  before  the  vomiting  set  in. 


*  "  Rev.  Mfed."  (1865),  pp.  205,  et  seq, 
j  Diihl.  Med.  Jour^t.,  May,  1S73. 
I  "Midwifery,"  p.  265. 
§  "Clin.  Med.,"  p.  107. 


THE   VOMITING   OF   PREGNANCY.  395 

2.  Next  we  come  to  cases  where  the  uterus  was  found  on 
post-mortem  examination  to  present  something  abnormal. 

Dance  *  observed  two  fatal  cases — I.  In  tlie  first,  death 
occurred  in  six  weeks;  there  was  found  to  be  pus  between 
the  uterus  and  phicenta,  and  pseudo-membranous  concre- 
tions between  the  uterus  and  decidua;  II.  in  the  second, 
death  in  twelve  weeks;  the  uterus  was  found  beginninp^  to 
rise  out  of  the  pelvis;  its  walls  were  scarcely  one  and  a  lialf 
lines  thick,  unusually  soft,  deeply  enj^orged,  and  of  a  violet- 
red  color.  III.  In  a  case  by  Chomel  pus  was  found  on  the 
external  surface  of  the  decidua. 

3.  The  next  category  of  cases  is  that  in  which  some  abnor- 
mal condition  of  the  uterus  7i'as  discovered  during  life.  I  ha\e 
collected  a  considerable  number  of  cases,  particulars  of 
which  are  subjoined,  tlie  facts  of  which  have  a  bearing  on 
the  present  discussion:  but  there  are  probably  others  on 
record  which  have  escaped  my  notice.  One  of  the  most 
important  cases  is  the  following: 

I.  Case  of  Vomiting  in  Pregnancy  caused  by  Retroversion  of 
the  Uterus. — Brian  records  f  a  most  interesting  case,  for 
reference  to  which  I  was  originally  indebted  to  Dr.  Barnes, 
and  of  which  the  following  is  a  slightly  abbreviated  account: 
X.,  aet.  25.  First  pregnancy,  six  years  ago,  ended  normally; 
second  ended  favorably,  three  years  ago,  but  there  was  some 
nausea  and  slight  pains.  Soon  after  recovering,  sustained 
accident,  being  thrown  out  of  a  carriage,  and  very  much 
frightened.  Leucorrhoea  then  noticed  and  continued;  has 
had  also  digestive  troubles.  Third  pregnancy  commenced 
in  March,  1856.  Vomiting  began  following  month,  and  in- 
creased in  severity.  In  May  she  kept  to  her  bed.  Intoler- 
able gastralgia,  constipation,  insatiable  thirst,  no  kind  of 
nourishment  retainable,  next  observed;  also  painful  clonic 
spasms  of  limbs,  profound  exhaustion  and  depression,  and 
sleeplessness.  On  May  2  first  seen  by  Brian,  who  was  im- 
plored to  procure  abortion.  Nothing  was  then  done,  but 
Professor  Moreau  saw  the  patient,  and  thought  the  vomit- 
ing would  cease  as  the  womb  rose  out  of  the  pelvis.  Case 
now  fell  under  other  treatment.  On  June  9  Brian  again  in 
charge  of  the  case,  the  patient's  condition  much  aggravated; 
he  insisted  on  a  careful  examination.  No  abdominal  tumor 
to  be  felt,  as   it  should   easily  have  been   in   the   patient's 

*  Rupert.  Gen.  d Anat.  et  de  Physiolog. 
f  Gaz.  Hebdomad.,  July  18,  1856. 


396  DISEASES   OF   WOMEN. 

emaciated  state.  On  June  4  Professor  Moreau  again  saw 
lier,  and  by  vaginal  examination  discovered  existence  of 
incomplete  retroversion,  fundus  deeply  lodged  in  the  cavity 
of  the  pelvis.  "He  ascertained  that  the  uterus  was  impris- 
oned in  the  curvature  of  the  sacrum  and  confined  on  all 
sides  by  the  osseus  cul  de  sac,  without  being  able  to  rise  up 
above  the  sacral  promontory.  As  soon  as  he  was  aware  of 
these  circumstances,  by  a  skilful  manoeuvre  he  disengaged 
the  fundus  uteri  from  its  abnormal  position,  causing  it  to 
ascend,  and  thus  bringing  it  into  the  longitudinal  axis  of 
the  abdomen."  After  this  operation  the  patient  felt  imme- 
diately relieved,  the  vomiting  ceased,  and  complete  recovery 
took  place. 

II.  Stolz  records  a  case  in  which  the  uterus  was  retro- 
verted,  and  the  excessive  vomiting  was  at  once  suspended 
on  replacing  the  uterus.     Eventually  abortion  was  induced. 

III.  In  a  case  by  Depaul,  at  seventh  month,  it  was  found 
that  the  internal  os  uteri  was  completely  obliterated.  In- 
cisions were  performed,  and  the  child  born  alive. 

IV.  Clay  *  records  a  case  of  sixth  pregnancy,  aet.  40,  at 
seventh  month.  He  determined  to  induce  labor.  Intro- 
ducing the  finger,  he  found  the  uterine  cervix  so  sensitive 
that  the  slightest  touch  produced  vomiting.  Finding  this 
to  be  the  case,  he  resolved  to  try  the  effects  of  rest.  Patient 
was  kept  in  bed,  and  in  twenty-four  hours  could  take  food. 
Persistence  in  the  rest  treatment  produced  a  perfect  cure. 

The  following  is  a  very  important  and  interesting  case 
recorded  by  Ulrich,f  for  reference  to  which  I  was  originally 
indebted  to  Dr.  Barnes,  and  which,  owing  to  its  being  the 
first  recorded  case  of  the  kind,  is  here  given  in  full: 

V.  Anteflexion  of  the  Gravid  Uterus;  severe  Nausea;  Death. 
—  Frau  Freudenburg,  thirtj'-four  years  of  age,  had  been 
healthy,  and  menstruated  regularly  up  to  the  date  of  her 
marriage  on  April  i.  Since  that  date  coitus  had  caused 
her  on  each  occasion  a  painful  feeling  in  the  abdomen, 
which  soon  became  so  great  that  she  at  last  resisted  all 
attempts  at  intercourse  on  the  part  of  her  husband.  On 
April  30  the  menses  appeared  as  usual;  during  May  she 
continued  in  her  usual  health.  At  the  end  of  May  the 
menses  did  not  appear.  On  June  i,  without  being  in  any 
other  way  unwell,  she  was  attacked  with  frequent  vomiting. 

*  Gaz.  Hebdomad.,  1857. 

f  "  Monatsschrift  fiir  Geburtsk."  1858. 


THE   VOMITING    OF   PREGNANCY.  39/ 

At  first  a  part  only  of  the  food  she  took  was  returned,  but 
very  soon  the  evil  increased  to  such  an  extent  that  all  food 
taken  into  the  stomach  was  vomited,  solids  as  well  as  fluids, 
and  when  the  stomach  was  empty  a  nauseous  sensation  re- 
mained for  a  long  time.  At  this  period  she  was  also  at- 
tacked with  pains  in  the  epigastrium,  which  came  on  in 
acute  paroxysms.  By  medical  advice  leeches  and  blisters 
were  applied  to  the  epigastrium,  and  all  sorts  of  narcotics 
and  antispasmodics  were  given  internally,  without  avail. 
The  patient  continued  vomiting  from  day  to  day,  and  the 
pains  robbed  her  of  her  night's  rest,  and  reduced  her  to  a 
weak,  nervous  condition.  Siie  resolved,  on  July  8,  to  seek 
relief  in  St.  Hedwig's  Hospital.  Her  condition  on  admis- 
sion was  the  following:  Bodily  frame  weak,  muscles  relaxed 
and  flabby,  atrophy  of  the  subcutaneous  fat,  on  the  front  of 
the  body  several  scattered  pigmentary  spots,  pulse  small 
and  frequent  always,  no  tenderness  of  subjacent  organs  by 
light  pressure  on  the  abdomen;  on  vaginal  examination  so 
high  that  the  posterior  lip  could  with  difliculty  be  reached, 
the  OS,  rounded  and  with  smooth  surface,  could  be  felt  in 
the  left  posterior  portion  of  the  pelvis.  The  enlarged  and 
doubled-up  body  of  the  uterus  could  be  felt  lying  behind 
the  right  horizontal  ramus  of  the  pubes.  By  the  aid  of 
gentle  pressure  with  the  other  hand  through  the  abdominal 
wall  the  uterus  was  found  to  be  markedly  anteflexed.  The 
position  of  the  flexion  could  be  distinctly  felt  through  the 
roof  of  the  vagina.  The  breasts  were  enlarged,  and  the 
areolae  darkened.  Menstruation  had  ceased  since  the  end 
of  April.  During  the  first  day  of  her  stay  in  hospital  the 
patient  sat  up  in  bed  in  a  bent-over  position;  she  was  tor- 
mented with  continuous  nausea  and  vomiting,  all  food  was 
returned  as  soon  as  swallowed,  and  large  quantities  of  tena- 
cious mucus  were  brought  up  from  the  empty  stomach; 
rest  and  ease  were  impossible,  owing  to  the  complete  loss 
of  sleep,  fearful  thirst,  and  obstinate  constipation.  The 
diagnosis  was  asthenia  from  the  vomiting  of  pregnancy, 
but  the  false  position  of  the  uterus  must  be  regarded  as  the 
essential  cause  of  the  evils,  and  its  further  expansion  would 
render  matters  worse,  and  produce  greater  irritation  of  the 
uterine  nerves;  therefore  an  attempt  must  be  made  manu- 
ally to  replace  the  dislocated  uterus.  Many  attempts  were 
made,  but  they  all  proved  unsuccessful;  as  the  strength  of 
the  patient  became  more  exhausted,  so  was  the  indication 
greater  for  the  artificial  production  of  abortion.     However, 


398  DISEASES   OF   WOMEN. 

I  did  not  resolve  on  this  until  I  had  made  a  last  trial  with 
the  various  well-known  internal  remedies,  of  which  tr.  iodi 
is  most  recommended.  With  the  consent  of  her  husband, 
according!}',  as  a  last  resource,  three  to  four  drops  of  tr.  iodi 
were  administered  daily.  After  fort}'  hours  of  this  treat- 
ment, the  repugnance  of  the  patient  to  this  treatment  be- 
came so  great,  that  only  by  repeated  persuasions  could  she 
be  induced  to  continue  it.  As  all  was  useless,  on  July  24, 
with  the  consent  of  her  husband,  an  attempt  was  made  to 
introduce  the  uterine  sound,  but  failed,  and  again  after  two 
days;  this  was  partly  owing  to  the  restless  movements  of 
the  patient,  and  partly  owing  to  the  high  position  of  the 
cervix  uteri;  the  sound  was  only  just  able  to  be  introduced 
into  the  cervix  uteri. 

I  made  a  third  attempt  on  July  31,  in  consultation  with 
Dr.  Brandt,  and  managed  at  last  to  introduce  the  sound  as 
far  as  the  bend;  to  have  pressed  it  on  further  would  have 
been  impossible,  owing  to  the  danger  of  wounding  the 
patient.  Unfortunately,  at  this  time  the  strength  of  the 
patient  was  so  far  exhausted,  that  even  in  the  case  of  the 
complete  emptying  of  the  uterus  an  unfavorable  termina- 
tion was  probably  to  be  expected.  Up  to  August  2  little 
change  occurred  in  the  health  of  the  patient;  then  the  vom- 
iting ceased  suddenly,  whilst  at  the  same  time  the  intellect 
became  disturbed,  light  delirium  alternating  with  deep 
drowsiness,  the  pupils  were  fixed  and  dilated,  and  conver- 
gent strabismus  set  in,  occasioned  by  the  paralysis  of  the 
external  rectus.     On  August  4  she  died. 

No  further  vaginal  examination  had  been  made  after  the 
last  introduction  of  the  sound.  In  laying  out  the  body  for 
post'inortevi  examination  twenty-four  hours  after  death, 
the  foetus  fell  out  of  the  vagina,  the  placenta  lay  within  the 
OS  and  was  brought  out  by  light  traction  on  the  umbilical 
cord.  The  post  vwrtcm  revealed  the  following:  On  the 
surface  of  the  hemispheres  underneath  the  arachnoid  were 
a  small  number  of  jelly-like  serous  exudations,  free  from 
blood-staining;  the  substance  of  the  brain  was  extraordi- 
narily ancemic;  at  the  base  of  the  brain,  around  the  origin 
of  the  sixth  nerve,  there  was  no  evidence  of  anything  ab- 
normal. The  chest-organs  were  healthy,  the  lungs  notably 
dry,  the  heart  small  and  firmly  contracted.  In  the  intes- 
tinal canal,  liver,  and  spleen,  no  pathological  changes  were 
found.  The  body  and  fundus  of  the  uterus,  considerably 
enlarged,  lay  directly  behind  the  right  horizontal  ramus  of 


THE   VOMITING   OF   PKEGNAXCY.  399 

the  pubes,  much  anteflexed;  the  length  of  the  body  of  the 
uterus  was  five  and  a  quarter  inches,  tlie  position  of  the 
flexion  was  three  inches  from  the  os.  On  the  under  surface 
the  walls  of  the  uterus  were  soft  and  flabby;  on  the  upper 
surface  they  \vere  much  condensed  and  very  firm.  On 
opening  the  cavity  of  the  uterus  the  placenta  was  seen  to 
have  had  its  attachments  to  the  lowest  segment  of  the 
uterus,  and  thus  had  harbored  the  foetus  above.  Above  the 
seat  of  flexion  in  the  upper  segment  of  the  uterus  no  free 
cavity  existed;  ttie  small  interval  between  the  rigid  walls  of 
the  uterus  was  filled  with  a  mass  like  a  placenta  firmly  ad- 
herent everywhere.  The  foetus  was  five  inches  long,  the 
umbilical  cord  six  and  a  half  inches. 

It  appears  evident  that  pregnancy  had  existed  for  nearly 
four  mouths,  and  that  after  conception  the  menses  appeared 
on  one  occasion;  and  it  is  my  decided  opinion  that  the 
bending  of  the  uterus,  and  consequent  hindrance  to  the 
regular  expansion  and  growth  of  the  uterus,  was  the  influ- 
ence producing  the  obstinate  vomiting. 

VI.  Dr.  Tyler  Smith*  recorded  a  case  in  which  nausea 
set  in  early  in  the  pregnancy.  When  the  patient  was  two 
months  pregnant  there  was  incessant  vomiting  and  extreme 
emaciation.  She  was  kept  alive  by  teaspoonful  doses  of 
l)eef-tea  every  half  hour,  and  injections  of  beef-tea.  When 
four  months  pregnant,  the  uterus  could  be  felt  above  the 
pelvic  brim.  Abortion  set  in  spontaneously  at  five  months. 
The  patient  did  well  for  three  weeks,  and  then  rapid  phthisis 
set  in. 

Dr.  Tyler  Smith  believed  that  "an  almost  poisonous  in- 
fluence seems  to  be  exerted  by  the  gravid  uterus  in  some 
constitutions."  Also  that  nausea  is  "  probably  cured  by 
the  distension  and  evolution  of  the  dense  structure  of  the 
uterus  after  impregnation,  or  by  the  pelvic  irritation  caused 
by  the  gravid  uterus  before  it  emerges  from  the  brim,  or 
from  both  these  causes."  f 

Ulcerations  of  the  os  uteri  have  been  considered  to  be  the 
cause  of  the  excessive  vomiting  by  several  authorities,  in- 
cluding Dr.  Henry  Bennet;  and  scattered  through  medical 
literature  will  be  found  cases  in  which  relief  from  sickness 
has  been  to  a  certain  extent  obtained  by  topical  applications 
to  the  OS  uteri. 

Severe  Nausea  associated  with  Anteflexion. — The  following 

*  "  Obst.  Trans.,"  vol.  i.  f  "  Manual  of  Obstetrics, "p.  99, 


400  DISEASES   OF   WOMEN. 

case,  observed  in  consultation  with  Dr.  Royston,  was  quoted 
in  my  original  paper:* 

VII.  Tlie  lady,  £et.  24,  quite  recently  married,  had  men- 
struated last  October  14,  1S70,  a  very  slight  discharge  being 
observed  on  November  3.  Since  November  3  there  had 
been  occasional  sickness,  and  from  the  end  of  January  up 
to  February  21,  when  I  first  saw  her  with  Dr.  Royston,  the 
sickness  had  been  severe.  Dr.  Royston  informed  me  that 
the  lady  was  pregnant,  that  when  first  called  in  to  see  her, 
about  a  fortnight  before,  the  sickness  was  most  severe,  and 
no  article  of  food  could  be  retained.  On  hearing  Dr.  Roy- 
ston's  account  of  the  symptoms  I  expressed  my  opinion  that 
the  uterus  was  acutely  anteflexed,  that  the  fundus  of  the 
uterus  would  be  found  to  be  low  down,  jammed  in  the 
pelvis,  and  that  this  was  the  explanation  of  the  symptoms. 
On  proceeding  to  make  an  examination  mj''  opinion  was 
found  to  be  exactly  verified:  the  os  uteri  lay  far  back,  the 
roof  of  the  vagina  was  projected  downward  and  backward 
by  the  enlarged  and  anteverted  and  -flexed  uterus,  and  the 
body  of  the  uterus  was  scarcely  to  be  felt  at  all  through  the 
abdominal  wall,  although  the  pregnancy  was  probably  of 
about  four  months'  duration. 

The  patient  had,  in  my  opinion,  suffered  from  anteflex- 
ion before  marriage,  and,  pregnancy  having  occurred,  the 
uterus  had  gone  on  growing  and  expanding  without  los- 
ing its  vicious  shape,  and,  indeed,  with  an  increasing  ag- 
gravation of  that  vicious  shape,  up  to  the  time  of  my  seeing 
her. 

The  evidence  that  anteflexion  existed  prior  to  marriage 
was  as  follows:  The  patient  was  never  able  to  dance  with- 
out discomfort.  She  had,  six  years  prior  to  marriage,  taken 
for  six  months  violent  horse  exercise,  to  which  she  was  pre- 
viously unaccustomed,  and  this  was  followed  by  losses  sim- 
ilar to  those  of  the  menstrual  periods,  and  by  diarrhoea. 
On  another  occasion,  a  year  later,  horse  exercise  again 
brought  on  similar  symptoms. 

In  this  case  the  advice  given  was  that  the  patient  should 
remain  altogether  in  the  horizontal  position  in  order  to 
allow  the  expanding  uterus  a  better  chance  of  escaping 
from  the  pelvis,  and  that  the  bowels  should  be  kept  regu- 
larly open.  The  result  of  this  treatment  was  that  the  chief 
symptom — the    nausea — underwent   at    once  a  most  mate- 

*  "Obst.  Trans.,"  vol.  xiii. 


THE  VOMITING  OF  PREGNANCY.  4OI 

rial  alleviation,  soon  disappeared,  and  delivery  at  full  term 
occurred. 

VIII.  Dr.  ^neas  Munro*  in  1872,  shortly  after  the  ap- 
pearance of  my  paper,  published  a  case  which,  to  use  his 
own  words,  "in  a  very  remarkable  manner  bears  out  to  a 
certain  extent  what  Dr.  Hewitt  has  said  on  the  matter." 
The  case  was  that  of  a  primipara,  aet.  21.  When  seen  first, 
in  the  third  month  of  pregnancy,  the  vomiting  had  become 
intense.  The  uterus  was  found  acutely  anteflexed  and 
quite  fixed.  An  attempt  to  push  the  uterus  up  failed.  The 
sound  passed  in  about  five  and  a  half  inches.  Some  days 
later,  no  relief  being  obtained,  and  symptoms  being  very 
urgent,  premature  labor  was  induced.  Recovery  complete. 
Dr.  Munro  in  one  place  states  that  there  was  no  jamming 
of  the  uterus  in  the  pelvis;  but  in  another  he  says  that  he 
found  it  so  fixed  in  its  abnormal  position  that  it  could  not 
be  moved  upward. 

Dr.  McClintock,f  in  an  essay  on  the  subject  published 
after  the  appearance  of  my  paper  in  the  "  Obstetrical  Transac- 
tions," gives  a  collection  of  cases  of  severe  vomiting  in  which 
premature  labor  was  induced  to  relieve  the  patient.  He 
confesses  that  "we  are  yet  very  much  in  the  dark"  as  re- 
gards the  etiology  of  the  sickness.  Dr.  McClintock  declined 
in  his  paper  to  accept  the  explanation  which  I  had  offered 
as  to  the  influence  of  flexion  of  the  uterus. 

IX.  Dr.  McClintock  J  gives  a  case,  that  of  a  primipara  aet. 
24,  who  at  the  end  of  two  months  was  found  suffering  se- 
verely from  sickness.  "The  uterine  tumor  could  not  be 
distinguished  above  the  pubes;  but  per  vaginam  the  body 
of  the  organ  was  felt  enlarged  and  slightly  anteverted,  as  is 
often  found  to  be  the  case  at  this  period  of  utero-gesta- 
tion."  Ten  days  later  the  patient  was  in  a  highly  danger- 
ous state,  and  abortion  was  induced. 

Dr.  McClintock  accepts  the  dictum  of  Dr.  Barnes  that  the 
normal  position  of  the  uterus  in  early  pregnancy  is  ante- 
version,  and  evidently  considers  that  in  the  above  case  there 
was  nothing  abnormal  in  the  condition  of  the  uterus.  It  is 
probable,  however,  from  the  facts  related  that  the  body  of 
the  uterus  was  really  abnormally  low  in  the  pelvis. 

One  of  the  arguments  used  by  Dr.  McClintock  and  some 
others,  which  seem  to  them  to  tell  against  the  influence  of 


*  Glasg.  Med.  Journ.,  Aug.,  1872.  f  Dub.  Med.  Jourti.,  1873. 

X  Ibid.,  May,  1873. 


402  DISEASES   OF   WOMEN. 

flexion  and  displacement  of  the  uterus  in  producing  the 
nausea  of  pregnancy,  is  that  in  cases  of  retroflexion  of  the 
gravid  uterus  sickness  is  not  always  present.  True;  but 
the  same  holds  good  respecting  retroflexion  of  the  non- 
gravid  uterus.  Sickness  is  not  a  constant  symptom  in  cases 
of  the  latter  kind,  but  I  have  known  most  severe  and  dis- 
tressing sickness  to  be  produced  by  retroflexion  in  the  non- 
gravid  state  which  has  been  almost  magically  relieved  by 
elevating  the  fundus,  thus  showing  in  the  most  indisputa- 
ble manner  that  the  sickness  was  due  to  tlie  flexion.  So 
again  with  anteflexion:  neither  in  tlie  gravid  nor  in  the  non- 
gravid  state  is  sickness  an  invariable  symptom,  but  this 
does  not  prove  that  the  anteflexion  is  not  responsible  for 
the  sickness  when  it  does  occur. 

A  very  important  contribution  to  th.e  patholog}-  of  the 
subject  is  that  of  the  late  Dr.  Copeman,  of  Norwich.  In 
1875  Dr.  Copeman  published*  a  paper  in  which  he  related 
three  cases,  of  which  the  following  particulars  are  given  in 
brief: 

X.  A  patient,  six  months  pregnant,  so  reduced  by  sick- 
ness that  fears  were  entertained  for  her  safety.  It  was  re- 
solved to  induce  premature  labor.  The  cervix  was  dilated 
with  the  finger  as  a  preparatory  step.  An  hour  later,  when 
further  measures  were  about  to  be  taken,  the  patient  was 
so  much  better  that  it  was  thought  best  to  wait.  From 
that  time  improvement  set  in,  there  was  no  return  of  sick- 
ness, and  delivery  at  full  term  occurred. 

Dr.  Copeman  was  struck  b)' this  case,  and  "wondered 
whether  the  relief  could  have  been  effected  b\'  his  having 
dilated  the  os  uteri  and  thus  removed  any  undue  tension 
that  might  be  producing  sympathetic  irritation." 

XI.  In  a  second  case  (where  "there  was  some  degree  of 
anteversion")  the  same  procedure  had  a  like  good  effect. 

XII.  In  a  third  case  equalh^  good  effects,  in  relieving  a 
patient  from  severe  sickness,  followed  the  dilatation  of  the 
OS  uteri  with  the  finger. 

This  paper  of  Dr.  Copeman's  attracted  my  attention,  and 
in  a  communication  to  the  British  Medical  Journal  a  fort- 
night after,f  in  speaking  of  Dr.  Copeman's  cases,  I  stated 


*  B^it.  Med.  Jown.  May  15,  1875.  Dr.  Ely  Smith  {Brit.  Med.  Joiati., 
Aug.  21,  1S75)  says  that  Dubois  first  noticed  this  effect  of  dilating  os  in 
arresting  vomiting. 

f  Ib;d.,  May  29.  1S75. 


THE  VOMITING  OF   PREGNANXY.  463 

that  they  offered  a  strong  confirmation  of  the  truth  of  the 
doctrines  I  had  previousl}''  expressed  on  the  subject.  The 
explanation  of  Dr.  Copeman's  success  I  held  to  be  that  the 
operation  of  dilating  the  os  uteri  was  itself  the  means  of 
righting  the  uterus,  for  the  os  must  have  been  pulled  for- 
ward in  order  to  dilate  it,  and  this  would  have  the  effect  of 
tilting  the  body  of  the  uterus  upward,  and  thus  (assuming 
that  they  were  cases  of  anteversion:  Dr.  Copeman  himself 
stated  that  one  was)  the  operation  reduced  the  displace- 
ment. I  further  added,  "It  may  be  said,  How  do  you  ex- 
plain the  cases  in  which  the  vomiting  persists  as  late  as  the 
eighth  month,  which  was  the  fact  in  Dr.  Copeman's  third 
case  ?  The  answer  is,  that  where  there  has  been  an  acute 
flexion  in  the  early  part  of  the  pregnancy,  as  the  uterus  en- 
larges (if  abortion  does  not  occur)  the  flexion  is  in  most 
cases  abolished,  and  the  effect  of  this  is,  that  the  sickness 
generally  disappears  under  such  circumstances.  But  the 
tissues  of  the  uterus  at  the  seat  of  the  flexioti  are  so  met  ivies  left 
in  a  diseased  state,  being  stiffened  and  unduly  resistant,  and  thus 
the  irritation  is  kept  up.  Dr.  Copeman's  treatment  would 
undoubtedly  tend  to  remove  this  stiffening  and  constraint." 

Dr.  Copeman  in  a  further  paper*  comments  on  various 
opinions  elicited  by  his  first  paper,  and  says  that  his  own 
opinions  were  not  sufficiently  matured  to  enable  him  to  give 
any  positive  explanation  of  tlie  causes  of  the  sickness,  but  he 
is  "  inclined  to  believe  that  in  such  cases  there  is  always  some 
irritating  condition  present,  which  induces  a  strain  upon 
the  neck  of  the  uterus,  or  perhaps  also  on  other  parts  of 
the  uterus." 

In  this  his  second  paper  Dr.  Copeman  relates  a  case 
which  most  curiously  corroborates  the  views  I  had  ex- 
pressed as  to  displacement  being  the  cause  of  the  sick. 
i:ess: 

XIII.  A  lady  in  her  second  pregnancy,  five  months  ad- 
vanced, was  very  sick;  she  had  frontal  neuralgia  also.  She 
had  for  some  weeks  taken  violent  exercise.  The  sickness 
and  the  neuralgia  continued.  The  abdomen  did  not  appear 
to  enlarge  as  much  as  usual.  On  examination  per  vaginatn 
the  head  was  found  low  down  in  front,  and  the  os  uteri  cor- 
responding with  the  promontor}^  of  the  sacrum.  "  It  seemed 
to  me,"  says  Dr.  Copeman,  "  that  the  uterus  was  anteverted 
so  as  to  allow  the  head  to  be  felt  below  the  level  of  the  os 

*  Brit.  Med.  Journ.,  Nov.,  1875. 


404  DISEASES  OF  WOMEN. 

uteri."  Dr.  Copeman,  b}^  gentle,  continued  pressure,  raised 
the  protruding  portion  of  the  uterus  out  of  the  lower  pel- 
vis and  restored  the  os  uteri  to  a  more  natural  position, 
after  which  he  prognosticated  no  further  vomiting  would 
occur.  And,  in  fact,  so  it  happened — the  cure  was  com- 
plete. 

In  this  case,  therefore,  the  nausea  was  cured  by  reducing 
the  uterus  to  its  proper  position.  Dr.  Copeman  not  having  em- 
ployed any  dilatation  of  the  os  as  in  the  other  cases,  and  it 
offers  a  remarkable  illustration  of  the  truth  of  the  critical 
remarks  which  I  had  before  offered  on  the  iiwdus  operandi  of 
Dr.  Copeman's  procedure.  In  fact,  the  patient  was  cured 
without  dilatation  of  the  os  uteri  at  all. 

XIV.  Case  by  Dr.  Copejuan* — Pregnant  eleven  weeks;  se- 
vere and  uncontrollable  vomiting  lately.  Fundus  tender 
on  pressure;  and  displaced  forward.  The  displacement  was 
rectified  and  bowels  opened.  Sickness  much  less  next  day, 
but  as  it  continued  slightly  os  was  dilated  with  finger. 
Cure. 

XV.  Case  by  Dr.  Cope7nan.\ — Six  weeks  pregnant;  three 
weeks  sickness.  Position  of  uterus  thought  to  be  normal; 
posterior  lip  hard  and  unj-ielding;  os  gradually  dilated, 
and,  after  two  days'  rest,  cure. 

XVI.  Case  by  Dr.  Copeman.\ — Six  weeks  pregnant;  nearly 
incessant  sickness  two  weeks.  After  dilatation  of  os  by 
finger  as  far  as  os  internum,  vomiting  ceased. 

I  subjoin  some  published  cases  in  which  dilatation  of  the 
OS  uteri  after  Dr.  Copeman's  plan  was  followed. 

XVII.  Case  by  Mr.  Atkinson%  of  Halifax. — Incessant 
vomiting  at  six  months,  in  a  multipara.  Vomiting  ceased 
after  digital  dilatation  of  os  uteri. 

XVIII.  Case  by  Dr.  Minot\  of  Boston. — A  sponge  tent  in- 
troduced into  the  cervix  allayed  the  vomiting. 

XIX.  Case  by  Dr.  Dukes.^^ — Patient,  set.  33.  Has  had  five 
children  and  five  miscarriages.  The  previous  pregnancy, 
after  eight  months'  incessant  vomiting,  was  relieved  by  in- 
duction of  premature  labor.  Now  pregnant  two  months. 
Remedies  now  failing,  the  os  was  dilated  digitally,  the  tis- 
sue being  found  very  hard  and  cartilaginous.  Vomiting 
was  at  once  relieved  and  soon  ceased  altogether. 


*  Brit.  Med.  Journ.,  Sept.,  187S.  f  Ibid.,  May.  1879. 

}  Ibirl.,  June.  1879.  §  Ibid.,  Nov.  6,  1S75. 

I  Ibid.,  Sept.,  1S76.  t  Ibid.,  Feb.  23,  1878. 


THE   VOMITING   OF   PREGXAN'CY.  465 

XX.  Case  by  Dr.  Gooch*  of  Eton. — Mother  of  two  chil- 
dren, pregnant  eight  months.  Incessant  vomiting  for  two 
months;  lying  on  back  produced  the  vomiting.  The  os 
uteri  found  hot  and  painful.  Dilatation  by  finger  and 
separation  of  membranes  round  os;  escape  of  much  offen- 
sive discharge;  relief  of  vomiting;  pregnancy  went  to  full 
term. 

XXI  and  XXII.  Tk'o  Cases  by  Dr.  L.  Rosenthal.  \ — Cure  by 
digital  dilatation  of  os — one  patient  in  second  pregnancy, 
the  other  a  primipara. 

XXIII.  Case  reported  by  Mr.  J.  T.  FryX  of  Swansea. — 
The  cervix,  and  especially  the  posterior  lip,  was  hard  and 
gristh'.  Neither  the  finger  nor  tangle  tent  could  be  intro- 
duced. A  long  and  slightly  anterior  curved  throat  forceps 
was  used,  and  gently  but  with  some  force  dilated;  the  os 
was  thus  dilated.  The  effect  immediate  in  removal  of  the 
vomiting.  The  patient  had  been  obliged  to  have  premature 
labor  induced  in  previous  pregnancy. 

XXIV^.  Case  by  Dr.  Murifio'^  of  Santia^^o. — Primipara, 
a^t.  22,  in  third  month  of  pregnancy;  sickness  severe.  On 
four  occasions,  at  intervals  of  a  day  or  two,  the  finger  was 
introduced  into  the  softened  cervix  as  far  as  internal  os. 
xVfter  a  week  sickness  ceased. 

The  following  is  a  series  of  cases  which  have  been  ob- 
served by  myself  during  the  last  ten  years,  illustrative  of 
the  question  now  under  consideration,  and  of  whicli  I  have 
preserved  notes;  but  I  have  seen  others  of  a  similar  kind, 
records  of  which  have  not  been  kept. 

XXV.  Retroflexion  of  the  Gravid  Uterus  causing  Severe 
Nausea. — The  subject  of  this  case,  now  published  for  the 
first  time  was  the  wife  of  a  medical  man.  She  consulted 
me  first  in  January,  1869,  for  severe  pain  in  the  chest  and 
heart.  The  uterus  was  found  to  be  retroflexed,  and  the 
last  catamenial  period  was  on  December  5,  about  seven 
weeks  previously.  On  February  20  a  second  omission  of 
menstruation  was  noted.  She  was  then  suffering  much 
from  sickness,  and  pregnancy  was  considered  to  be  pres- 
ent. This  pregnancy  ended  favorably;  but  I  saw  nothing 
of  the  patient  further  until  the  year  1872  (January  24). 
Patient  now  26;  has  had  three  children,  two  of  these  since 
I  last   saw  her;  last  child  is  a  little  over  three  years  old. 

*  Brit.  Med.  Jount.,  Sept.  23,  1878.  \  Ibid..  Aug.,  1879. 

X  Ibid.,  March  13,  18S0.  §  Lond.  Med.  Record,  Feb.  15,  1878. 


406  DISEASES   OF  WOMEN. 

Patient  now  six  weeks  pregnant.  She  is  suffering  from 
severe  sickness.  The  uterus  is  found  to  be  retrofiexed.  A 
ring  pessary  (Hodge-shaped)  was  applied,  and  she  went 
liome.  On  February  22  I  was  sent  for  and  found  her  ex- 
tremely ill,  suffering  from  intense  sickness.  The  sickness 
had  induced  severe  jaundice  and  an  extreme  depression 
and  feeling  of  collapse.  The  ring  pessary  had  ceased  to 
do  its  work  properly,  being  too  small  for  the  increased  size 
of  the  uterus,  and  the  organ  was  retroverted  over  the  top 
of  the  pessary.  A  larger  instrument  was  applied.  The 
patient,  who  was  in  a  most  alarming  state  of  depression, 
very  speedily  felt  better,  and  she  visited  me  at  my  house 
on  April  2,  also  on  April  17;  but  on  April  19  I  was  sum- 
moned to  see  her  again  with  a  repetition  of  the  same  severe 
symptoms,  the  vomiting  having  returned  in  a  most  intense 
degree.  Again  I  found  the  mechanism  of  the  support  at 
fault;  the  exertion  of  coming  to  my  house  had  been  too 
much,  and  the  uterus  was  still  displaced.  Relief  followed 
its  readjustment;  but  great  difficulty  was  found  in  retain- 
ing the  uterus  in  its  place  (though  it  was  easy  enough  to 
replace  it)  owing  to  the  indisposition  of  the  patient  to  keep 
quiet.  Whenever  the  uterus  was  in  proper  position  the 
symptoms  abated  as  if  by  magic;  but  recurred  as  speedily 
when  the  fundus  succeeded  in  eluding  the  action  of  the 
pessary.  Finally,  an  end  was  put  to  the  case  by  the  occur- 
rence of  premature  labor  on  June  26,  the  patient  being  then 
a  little  over  six  months  advanced  in  pregnancy. 

The  husband  of  this  lady  informed  me,  in  answer  to  a 
letter  in  May,  1876,  that  since  that  time  she  slowly  recovered 
her  strength,  but  that  every  now  and  then  she  is  liable  to 
attacks  of  "  biliary  colic."  She  does  not,  he  states,  now 
suffer  from  the  retroflexion.  She  has  been  pregnant  once 
since,  but  did  not  go  her  full  time  owing,  he  believes,  to 
anxiety  and  fatigue  in  nursing  her  sick  children.  He  re- 
marks, as  a  curious  circum,stance,  that  she  has  only  been 
sick  when  pregnant  with  girls. 

The  case  is  a  most  interesting  one,  the  history  of  retro- 
flexion as  affecting  the  pregnancies  being,  in  regard  to  many 
of  the  details,  known  to  me  from  personal  observation.  I 
saw  her  suffering  from  sickness  at  the  beginning  of  her 
second  pregnancy,  and  relieved  her  from  the  displacement 
so  that  she  went  her  full  time.  Further,  I  saw  her  in  her 
fourth  pregnancy  again  affected  with  retroflexion,  and 
again   suffering  from  sickness,  but  on   this   occasion  in  a 


THE  VOMITING   OF   PREGNAN'CY.  4O7 

much  more  severe  form.  On  three  or  four  distinct  occa- 
sions during  this  fourtli  pregnancy  the  sickness  actually 
threatened  to  destroy  her,  but  each  time  it  was  arrested  by 
the  raising  of  the  uterus  from  its  retroflexed  position.  The 
repetition  of  the  disorder,  however,  ended  in  premature 
labor  at  about  six  and  a  half  months;  but  had  the  patient 
been  more  careful  and  less  wilful,  it  is  probable  that  preg- 
nancy would  have  gone  on  to  full  term. 

XXVI.  Haiisca  due  to  Anteflexion  of  the  Gravid  Uterus. — 
A.  M.,  aet.  21,  patient  at  University  College  Hospital,  1874. 
The  notes  by  Dr.  E.  M.  Skerritt.  Married  two  and  a  half 
years,  no  children,  no  miscarriages.  Menstruation  never 
regular,  intervals  occasionally  three  or  four  months,  and 
always  scanty  and  very  painful.  She  has  not  menstruated 
for  the  last  four  months,  the  last  time  after  a  previous 
interval  of  four  months.  The  present  illness  for  the  last 
four  months;  gradually  the  symptoms  have  become  worse. 
For  the  last  three  weeks  she  has  been  confined  to  her  bed. 
Her  chief  complaint  is  of  pain  of  an  aching  or  griping 
character  at  the  lower  part  of  the  abdomen,  mucli  more 
intense  of  late,  and  accompanied  by  nausea  and  vomiting 
occurring  both  on  getting  up  and  during  the  day.  Ex- 
pression painful,  areolae  enlarged,  distinct  brown  pigmen- 
tation, areolar  glands  enlarged;  abdomen  not  distended, 
resonant,  more  resistance  to  pressure  on  left  side.  Pain 
referred  to  umbilicus,  described  as  "cutting,"  with  occa- 
sional exacerbations.  General  abdominal  tenderness.  On 
deep  pressure  over  pubes  a  tumor  is  felt  rather  far  back, 
giving  impression  of  being  the  top  of  a  tumor  rising  up 
from  the  pelvis,  with  a  smooth  rounded  upper  surface,  two 
or  three  inches  wide,  flattened  from  before  backward,  and 
very  tender.  Bladder  had  been  previously  emptied.  Os 
uteri  found  to  be  very  high  up  and  rather  far  back.  In 
front  of  it  can  be  felt  what  seems  to  be  a  considerable 
swelling,  extending  laterally,  firm,  smooth,  rounded,  and 
very  tender.  Such  was  the  state  on  admission.  The 
vomiting  continued  at  intervals  for  a  few  days,  the  pain 
also,  the  tumor  felt  above  pubes  slowly  increasing  in  size. 
On  March  15  Mr.  Rigden,  the  resident  medical  officer,  ex- 
amined her,  and  expressed  his  belief  that  the  tumor  was 
the  anteflexed  uterus  inclined  more  to  the  left  side  than 
right.  On  March  18  the  tumor  had  risen  higher,  reaching 
now  to  within  two  inches  of  the  umbilicus.  The  vomiting 
and   retching  still    occasionally    severe.       Placental    bruit 


408  DISEASES   OF  WOMEN. 

heard  above  right  Poupart's  ligament.  On  March  19  I 
was  requested  to  see  the  patient  for  the  first  time.  I  noted 
that  the  condition  of  the  breasts  alone  sufficed  to  indicate 
existence  of  pregnancy.  The  tumor  above  the  pubes  is  of 
the  shape  and  size  of  a  four  months'  gravid  uterus.  The 
OS  and  cervix  are  high  up  and  far  back,  but  not  changed 
in  regard  to  softness  in  the  way  usually  met  with  in  preg- 
nancy. The  body  of  the  uterus  not  now  to  be  felt  through 
vaginal  roof.  I  expressed  my  opinion  that  the  patient  was 
certainly  pregnant;  that  the  previous  observations  made 
by  Mr.  Rigden  and  others  left  no  doubt  that  the  uterus  had 
been  up  to  quite  recently  anteflexed,  and  that  the  enlarged 
uterus  had  now  escaped  from  the  pelvis. 

March  20. — No  vomiting  or  retching  last  night,  no  pain, 
no  vomiting  this  morning. 

March  21. — Pain  latter  part  of  night,  felt  very  sick  before 
breakfast,  and  on  taking  food  vomited  at  once.  Tumor 
still  tender.  Says  that  as  long  as  she  lies  still  there  is  no 
nausea,  but  that  it  occurs  on  moving  in  bed. 

March  23. — Slight  nausea  when  she  sits  up  in  bed  early 
in  the  morning.     Free  from  nausea  now  as  a  rule. 

March  24. — Nausea  still  a  little;  vomited  at  teatime. 

Afarch  28. — Was  sick  on  first  sitting  up  in  bed  this  morn- 
ing; not  sick  since,  though  she  has  felt  so.  Not  sick 
yesterday,  but  had  nausea  as  before.  Got  up  for  first  time 
to-day.  Complains  of  occasional  shooting  pain  in  abdo- 
men. 

March  30. — Patient  has  not  vomited  since  28th,  though 
she  feels  nausea  at  first  sitting  up.  The  patient  left  the 
hospital  to-day  convalescent. 

XXVI I.  Retroflexion  of  Gravid  Uterus;  Severe  Nausea. — 

Mrs. ,  set.        ,  has    had    three   children;    suffered  from 

severe  sickness  in  all  the  pregnancies.  Is  now  two  and  a 
half  months  pregnant,  and  suffering  from  severe  sickness. 
The  OS  is  found  far  forward,  the  uterus  much  retroflexed. 
Ordered  to  lie  on  the  face.  Report  later  on  states  that  the 
sickness  was  relieved  at  once;  she  had  it  slightly  up  to  four 
months,  when  it  absolutely  ceased.  She  was  delivered 
safely  at  full  time. 

XXVIII.  Anteflexion  of  Gravid  Uterus;  Severe  Nausea. — 
Mrs. ,  set.  33,  has  had  eight  children  and  three  mis- 
carriages. Now  three  and  a  half  months  pregnant;  always 
suffers  severely  from  sickness  during  pregnancy,  together 
with  intense  mental  depression  during  the  first  half  of  preg- 


THE   VOMITING   OF   PREGNANCY.  409 

nancy,  and  during  the  latter  half  from  swelling  of  the  legs, 
varicose  veins,  and  general  distress.  On  this  occasion  tents 
have  been  introduced  to  procure  abortion  and  relieve  the 
sickness,  but  ineffectually.  On  examination  the  uterus  is 
found  to  be  anteflexed,  the  os  uteri  swollen,  the  anterior 
wall  of  cervi.x  thin.  Rest  was  ordered.  Further  history 
not  known. 

I  have  one  case  to  record  in  which  dilatation  was  had  re- 
course to: 

XXIX.  Mrs. ,  aet.  ;^;^,  multipara.  Very  severe  sick- 
ness arising  from  anteflexed  uterus,  with  great  hypertrophy 
and  hardening  of  cervix  and  os.  At  the  seventh  week  of 
pregnancy,  death  tiireatencd  by  continued  sickness,  al- 
though the  sickness  was  at  first  relieved  by  use  of  a  pes- 
sary. Cervix  dilated  by  metallic  dilator,  resistance  to  dila- 
tation very  great.  Following  day  relief,  but  abortion  oc- 
curred on  second  day  after.  Patient  died  a  little  over  a 
fortnight  later  from  exhaustion. 

XXX.  Anteflexion  of  Gravid  Uterus ;  Severe  Nausea. — Mis. 

,  aet.  34,  has  had   four  children,  now  pregnant  for  fifth 

time.  Last  child  four  years  ago.  Is  pregnant  three  months. 
Her  expression  was,  "Can  you  relieve  me  of  the  constant 
sickness?"  On  examination  it  is  found  that  the  uterus  is 
anteflexetl,  and  the  body  is  quite  low  down  in  front  while 
the  OS  is  far  back,  the  uterus  being  thus  jammed  downward 
behind  the  symphysis  pubis.  The  patient  was  ordered  to 
remain  in  bed  for  a  week,  and  to  lie  on  the  sofa  for  three 
weeks  afterward.  Food  to  be  given  every  hour  in  small 
quantities.  A  fortnight  after  reported  to  be  much  better, 
sickness  hardly  more  than  once  a  day.  A  month  later,  a'ole 
to  move  about  easily  without  sickness.  Visited  me,  when 
eight  mo'iths  pregnant,  quite  well. 

The  cases  which  have  been  recorded  in  the  preceding 
pages  convey  sufficient  proof  of  the  great  efficacy — it  may 
be  almost  said  of  the  eomplete  efficacy — of  certain  mechani- 
cal procedures  at  the  os  and  cervix  uteri  in  relieving  the 
sickness  of  pregnancy  in  its  severest  form.  I'think  there  can 
be  no  doubt  that  the  phenomena  recorded  are  thorouglily 
explained  by  adopting  the  view  that  in  these  cases  the  tis- 
sues round  the  internal  os  uteri  are  prevented  undergoing 
proper  expansion.  This  impediment  to  expansion  is  either 
an  actually  present  flexion  of  the  uterus  or  a  contraction 
and  condensation  of  these  tissues,  the  result  of  a  previously 
existing  flexion. 


4IO         DISEASES   OF   WOMEN. 

It  is  a  noteworthy  fact  that  in  some  of  the  cases  recorded 
the  cervix  was  found  so  hardened  and  resistant  that  very- 
great  difficulty  was  found  in  expanding  it.  Cases  of  this 
kind  were  always  multiparae,  and  the  inference  is  natural 
that  only  in  multiparae  is  it  likely  that  this  inordinate  resist- 
ance to  mechanical  ar///?67'cz/ expansion  will  be  met  with. 

Dr.  Aubert*  in  his  essay,  "Influence  of  the  Movements 
of  the  Uterus  on  the  Vomiting  of  Pregnancy,"  describes  a 
case  where  during  digital  examination  the  attempt  to  push 
the  uterus  to  one  side  by  the  finger  produced  immediately 
nausea,  which  would  have  ended  in  vomiting  had  he  per- 
sisted. The  patient  was,  as  afterward  appeared,  in  the 
second  month  of  pregnancy.  A  second  examination,  made 
at  the  end  of  the  fifth  month,  showed  that  lateral  pressure 
produced  nausea,  but  less  severe  than  on  the  former  occa- 
sion. Aubert  discusses  the  subject  of  this  provocation  of 
nausea  as  a  diagnostic  measure  in  the  early  months  of 
pregnancy.  He  cites  Gueniot,  who  gives  cases  wheie  rest 
in  bed  appeared  in  some  cases  to  arrest  the  vomiting  of 
pregnancy.  He  notes  also  that  Stolz  found  pressing  the 
uterus  upiuard  did  not  give  rise  to  vomiting.  Aubert  ob- 
served vomiting  in  17  out  of  37  primiparse,  while  of  17  mul- 
tiparae only  4  had  vomiting.  Gueniot  in  51  severe  cases  had 
12  primiparae  and  39  multiparae.  In  the  discussion  follow- 
ing Dr.  Aubert's  paper  it  was  stated  by  M.  Icard  that  in 
certain  intractable  cases  vomiting,  having  lasted  three  or 
four  months,  had  disappeared  on  rectifying  the  displace- 
ment found  to  exist  on  digital  examination.  M.  Chatin  had 
seen  many  cases  where  the  vomiting  ceased  on  altering  the 
position  of  the  uterus  when  displaced. 

XXXI.  In  a  case  by  Prof.  Tarnierf  of  Paris,  a  multipara, 
three  months  pregnant,  had  incessant  vomiting,  which  was 
allayed  by  plugging  the  vagina  with  wadding,  thus  pre- 
venting, as  he  thought,  the  uterus  from  moving  about  and 
being  shaken. 

GENERAL    COMMENTARY, 

Some  writers,  as  Dr.  Barnes,  consider  the  vomiting  of 
pregnancy,  in  severe  cases,  due  to  tension  or  stretching  of 
the  uterine  fibres.  This  may  be  in  part  the  cause.  For  it 
seems  likely  that  irritation  might  be  produced  by  an  undue 

*  Lyon  M^dic,  Oct.,  1871.  p.  431. 

\yourn.  de  M/d.  et  Chir.  and  i?nV.  Med.  Journ.,  Aug.  28,  1875. 


THE   VOMITING   OF   PREGNANCY.  4II 

degree  of  such  stretcliing.  But,  supposing  flexion  to  be 
present,  this  would  be  likely  to  give  rise  to  undue  stretch- 
ing and  tension  of  the  uterine  fibres.  While  undue  com- 
pression is  present  on  the  concave  side  of  the  bend,  there 
would  be  increased  tension  and  stretching  on  the  convex 
side.  To  those,  therefore,  wlio  consider  the  tension  theory 
the  best,  I  would  point  out  that  in  the  flexed  uterus  while 
undergoing  the  process  of  expansion  such  tension  will  be 
greatly  increased  and  irritation  arising  therefrom  consider- 
al)ly  aggravated.  My  own  impression,  however,  is  that 
compression  is  the  particular  and  tangible  irritating  ele- 
ment in  such  cases.  The  very  decided  effects  produced  in 
some  of  Dr.  Copeman's  cases  by  dilating  the  cervi.x  illus- 
trate the  efficacy  of  removal  of  condensation  and  tension 
around  the  internal  os  uteri  in  relieving  the  sickness;  and 
Dr.  Copeman's  cases  offer  evidence  of  the  most  convincing 
character  in  this  direction. 

Where  vomiting  persists  to  the  latter  months  of  preg- 
nancy, the  condensation  at  the  internal  os  has  not  been 
entirely  removed  by  the  unfolding  and  expansion  of  the 
uterus  (see  p.  372).  The  structures  round  the  internal  os 
uteri  are  not  fully  dilated  up  to  quite  the  end  of  pregnancy 
in  primiparaj,  and  thus,  although  the  uterus  may  have  lost 
its  flexion,  it  by  no  means  follows  that  the  nervous  filaments 
around  the  internal  os  are  relieved  of  condensation,  tension, 
and  pressure  at  the  same  moment  that  the  flexion  is  re- 
lieved. When  the  flexion  is  not  of  long  standing,  by  the 
fifth  month  the  uterus  will  have  become  relieved  either  by 
miscarriage  or  by  unfolding.  But  if  the  cervical  tissues 
are  much  condensed  by  long-standing  flexion  the  arrival  of 
mid-pregnancy  may  not  give  the  expected  relief. 

Dr.  Aveling's  remarks  on  the  subject  of  the  nausea  of 
pregnancy*  are  as  follows: 

Vomiting  during  Gestatio7i. — This  troublesome  and  occa- 
sionally dangerous  disorder  has  undoubted  relations  to 
posture.  It  has  the  name  of  morning  sickness  from  the 
fact  that  it  appears  when  the  patient  leaves  her  bed  and 
assumes  the  erect  posture.  It  is  evidently  reflex  in  its 
cliaracter,  and  is  probably  produced  by  hypostatic  hyper- 
emy  and  hyperaesthesia  of  the  uterus.  Certain  it  is  that  all 
obstetricians  recommend  the  recumbent  position  for  its  re- 

*On   Influence  of  Posture  on  Women.      Obst.  Jour.,  F,eb.,  1S77  (No, 

47'.  P-  7=2. 


412  DISEASES   OF   WOMEN. 

lief,  and  often  with  great  success.  But  Dr.  Clay  of  Man- 
chester goes  further  than  this,  and,  believing  gestational 
sickness  to  be  dependent  upon  congestion  and  tenderness 
of  the  cervix  uteri,  advises  a  position  of  the  body  calculated 
to  relieve  the  os  and  cervix  from  pressure  against  the  pelvic 
viscera,  best  accomplished  by  lying  on  the  back  with  the 
hips  raised  and  head  low.  .  .  .  Displacements  of  the  uterus 
have  been  suggested  as  producing  vomiting  during  gesta- 
tion, and  this  is  not  unlikely,  for  mechanical  hyperemy  is 
often  caused  by  them,  and  it  would  have  the  same  effect  as 
hypostatic  hyperemy  upon  the  uterine  nerves." 

As  bearing  on  the  discussion  of  the  present  question,  it 
must  be  recollected  that  until  recently  it  was  not  generally 
known  or  understood  that  anteflexion  of  the  uterus  in  the 
non-gravid  state  is  a  common  affection,  nor  that  anteflexion 
of  the  gravid  uterus  is  common.  In  the  various  text-books 
on  obstetrics,  anteversion  of  the  gravid  uterus  is  not  even 
mentioned  as  a  possible  occurrence.  This  observation  does 
not  apply  to  some  of  the  text-books  published  on  the  Con- 
tinent. One  of  them,  at  all  events  (M.  Cazeaux),  alludes  to 
it.  I  myself  was  not  aware  of  the  possibility  of  its  occur- 
rence until  I  had  encountered  a  case  in  actual  practice — a 
case  which  I  described  in  the  year  1865  at  a  meeting  of  the 
Obstetrical  Society  of  London.*  I  believed  it  then  to  be  a 
very  rare  disorder,  but  my  observations  since  that  time  have 
convinced  me  that  in  a  mild  form  it  is  very  common;  and 
further,  that  it  is,  as  I  have  already  fully  stated,  in  a  more 
severe  form  associated  with  obstinate  sickness.  Looking 
back  to  my  notes  of  this  first  case  I  find  it  recorded  that 
obstinate  sickness  occurred,  although  I  did  not  then  attach 
any  particular  signification  to  the  symptom. 

Anteflexion  of  the  uterus  is  more  commonly  found  to  be 
the  cause  of  sickness  in  pregnancy  than  retroflexion,  be- 
cause it  is  rather  more  rare  for  the  retroflexed  uterus  to 
become  impregnated.  Hence  the  result,  clinically,  that 
when  obstinate  sickness  occurs  it  is  infinitely  more  likely  to 
be  due  to  anteflexion  than  to  retroflexion. 

The  principal  arguments  in  favor  of  the  view  that  the 
vomiting  of  pregnancy  is  due  to  flexion  of  the  organ  may 
be  briefly  recapitulated:  (i)  Many  women  have  no  sick- 
ness, therefore  it  is  not  an  essential  part  of  pregnancy. 
(2)  It  is  mostly  limited  to  the  first  half  of  pregnancy,  being, 

*"Obst    Trans.,"  VvjI.  vii.,  p.  170, 


THE  VOMITING   OF   PREGNANXY.  413 

indeed,  in  many  instances  limited  to  the  first  two  or  three 
months.  This  is  precisely  the  time  during  which  the  uterus 
is  most  liable  to  suffer  from  flexion;  for  when  it  rises  into 
the  abdomen  such  flexion  can  hardly  occur.  (3)  It  is  pro- 
duced almost  universally  by  the  standing  or  sitting  posi- 
tion, which  would  be  likely  to  intensify  or  exaggerate  tem- 
porarily an  existing  flexion.  (4)  It  is  suspended,  in  all  but 
the  very  severe  cases,  if  the  patient  remains  in  bed  for  a 
day  or  two,  during  which  time  no  such  exaggeration  of  the 
flexion  by  standing,  etc.,  occurs.  (5)  It  occurs  to  a  very 
marked  degree  in  cases  which  are  known  to  be  the  subject 
of  flexion  at  the  time  of  pregnancy.  (6)  Severe  sickness 
and  a  decided  tendency  to  abortion  are  very  frequently 
associated  in  the  same  case,  from  which  it  follows  that  it  is 
not  unlikely,  at  all  events,  that  the  same  cause  is  operative 
in  producing  both  effects.  (7)  Lastly,  I  would  mention  my 
own  observations  as  to  the  effect  of  positional  treatment  in 
cases  of  flexion  of  the  gravid  uterus,  attended  with  sickness 
more  or  less  severe.  These  are  to  the  effect  that  since  my 
attention  has  been  particularly  directed  to  the  subject  I 
have  treated  several  such  cases,  and  that  I  have  found  the 
sickness  always  to  subside,  or  to  undergo  an  immediate 
and  remarkable  amelioration,  by  so  placing  the  patient  or 
by  so  changing  the  position  of  the  uterus  as  to  favor  the 
reduction  of  the  existing  flexion. 

The  history  of  these  cases  is,  I  believe,  as  follows:  The 
uterus  is,  at  the  time  pregnancy  begins,  in  a  state  of  flex- 
ion— generally  slightly  so,  sometimes  more  marked  in  de- 
gree. The  uterus  expands,  the  walls  increase  in  thickness, 
there  is  consequently  an  additional  degree  of  compression 
of  the  tissues  at  the  seat  of  the  flexion.  The  natural  effect 
of  the  increase  of  the  expansion  would  be  to  unfold  the 
uterus  and  straighten  it,  and  in  point  of  fact  this  result  is 
achieved  in  most  cases.  But  while  this  process  is  going  on 
the  tissues  at  the  flexure  are  compressed  unduly,  particu- 
larly in  certain  positions  of  the  body,  and  reflex  nausea  or 
vomiting  may  be  thus  produced. 

TREATMENT  OF    THE    VOMITING    OF    PREGNANCY. 

In  ordinary  simple  cases  it  will  be  found  that  this  trou- 
blesome symptom  can  be  effectually  relieved  by  attention 
to  certain  rules  as  to  the  position  of  the  body.  The  pa- 
tient must  be  induced  to  maintain  the  horizontal  position 


414  DISEASES   OF   WOMEN. 

as  much  as  possible,  and  it  will  generally  be  found  that 
this  is  sufficient.  Attention  should  of  course  be  paid  to  the 
state  of  the  bowels.  After  the  fourth  month  the  tendency 
to  sickness  disappears  in  most  instances,  and  the  patient 
can  then  move  about  or  sit  upright  witliout  nausea.  The 
degree  to  which  it  is  necessary  to  enforce  the  horizontal 
position  depends  on  the  severity  of  the  sickness. 

In  severe  cases,  where  the  above  treatment  has  no  suffi- 
ciently good  result,  the  state  of  the  uterus  must  be  ascer- 
tained, and  means  should  be  taken  to  rectify  any  malposi- 
tion which  may  be  detected.  Various  mechanical  devices 
may  be  put  in  force  to  aid  the  body  of  the  uterus  in  rising 
up  into  its  proper  position.  These  will  vary  according  as 
the  body  of  the  uterus  is  turned  forward  or  backward.  A 
simple  air-ball  pessary  acts  well  in  cases  of  anteflexion,  and 
a  well-fitted  Hodge-shaped  pessary  is  proper  for  cases  of 
retroflexion.  The  action  of  the  pessar}'  must  be  aided  by 
maintenance  of  the  horizontal  position.  When  the  uterus 
is  restored  to  its  place  a  pessary  may  not  be  further  re- 
quired. Indeed  a  pessary  ma)^  not  be  required  at  all  if  the 
uterus  can  be  raised  into  its  place  by  pressure  with  the  fin- 
ger, aided  by  positional  treatment. 

Where  the  sickness  is  not  relieved  by  any  of  the  above 
procedures,  the  case  will  probably  be  one  in  which  the  cer- 
vix uteri  is  very  hard  and  unyielding.  Under  these  cir- 
cumstances the  plan  recommended  by  Dr.  Copeman  should 
be  put  into  practice,  and  the  cervix  dilated  art'ficially  in 
order  to  remove  the  compression  and  tension  around  the 
internal  os  uteri.  In  my  opinion,  this  treatment  will  be 
found  really  necessary  in  exceptional  cases  only;  in  m}^  own 
practice  I  have  only  found  the  other  and  more  simple  meas- 
ures fail  in  relieving  the  sickness  in  one  instance. 

In  most  of  the  cases  recorded  as  treated  by  Copeman's 
plan  the  dilatation  was  easily  effected,  and  in  these  instances 
probably  it  was  not  really  necessary;  but  in  two  of  them  cer- 
tainly the  dilatation  was  more  difficult  to  accomplish;  in  one 
of  these  a  two-bladed  dilator  was  employed  for  the  purpose, 
in  another  a  throat  forceps.  There  is  of  course  danger  of 
producing  abortion  b}'  the  employment  of  any  instrument 
passing  through  and  beyond  the  internal  os  uteri.  The  fin- 
ger would  be  the  safest  dilator,  but  in  the  really  difficult  cases 
it  may  be  found,  as  in  the  case  related  at  page  409,  that  the 
finger  could  not  be  introduced  at  all.  Careful  dilatation  with 
&  steel  two-bladed  dilator — on  the  principle  of  the  one  repre- 


DISEASES   OF   THE   OS   AND   CERVIX    UTERI.       415 

sentecl  at  page  365,  but  larger  at  the  extremity  of  the  blades 
— seems  to  me  to  be  the  best  method  of  accomplishing 
the  desired  end,  if  the  finger  cannot  be  made  to  enter  the 
cervix.  The  dilatation  should  not  be  rapidly  effected,  the 
object  being  to  gently  release  the  tension  of  the  structures 
without  exciting  contractions  of  the  uterus.  When  the  os 
externum  admits  or  can  be  made  to  admit  the  finger  it 
would  be  best  to  employ  the  finger  for  the  further  dilatation 
of  the  canal  higher  up.  It  must  be  recollected  that  the  cer- 
vical canal  has  a  length  of  rather  over  one  inch,  and  it  ap- 
pears necessary  to  dilate  the  canal  at  its  upper  extremity 
in  order  to  give  the  necessary  relief  under  such  circum- 
stances. The  employment  of  the  finger  has  one  drawback 
— namely,  that  as  a  rule  the  finger  cannot  be  readily  intro- 
duced so  far  as  the  internal  os  uteri  without  passing  a  con- 
siderable part  of  the  hand  into  the  vagina. 

The  induction  of  premature  labor  could  be  practiced,  as 
a  last  resource,  when  other  measures  are  found  to  be  of  no 
avail  and  the  life  of  the  patient  is  at  stake. 


CHAPTER    XXIX. 
Diseases  and  Injuries  of  the  Os  and  Cervix  Uteri. 

The  "  Ulceration"  Theory  of  Uterine  Disease — Laceration  of  the  Cervix 
Uteri:  its  Effects  and  Results — Dr.  Emmet's  Views  on  the  Subject — 
His  Method  of  Treatment — Importance  of  Eversion  of  the  Cervical 
Lining:  Causes  of  the  same — Hypertrophy,  Cystic  Degeneration  of 
the  Os  Uteri,  etc. 

Ulcerations  of  the  Os  Uteri — Erosions — True  Ulcerations — Syphilitic 
Ulcerations. 

DISEASES    OF    THE    OS    AND    CERVIX    UTERI. 

"A  whole  generation  of  physicians,"  says  Dr.  Emmet,* 
"has  been  misled  by  the  delusion  of  chronic  inflamma- 
tion and  ulceration  of  the  uterus — conditions  which  no  one 
has  yet  been  able  to  demonstrate  on  the  dead  body." 

While,  however,  most  of  the  so-called  ulcerations  and  in- 
flammations can  be  shown  to  be  referable  to  changes  of 
other  parts  of  the  uterus,  we  have  of  late  learned  that  there 

*  Loc.  cit,,  p.  129. 


4l6  DISEASES   OF   WOMEN. 

are  local  conditions  and  diseases  of  the  os  and  cervix 
which  appear  to  require  more  attention  than  they  have  yet 
received — namely,  the  changes  incident  upon  or  following 
after  the  laceration  of  the  cervix  uteri  during  parturition. 
It  is  not  a  little  remarkable  that,  largely  used  as  the  specu- 
lum has  been  in  the  investigation  and  treatment  of  the  dis- 
eases of  the  uterus,  cases  of  severe  lacerations  of  the  cervix 
seem  to  have  been  overlooked  until  a  very  recent  period 
even  by  those  who  were  most  in  the  habit  of  employing  the 
instrument. 

It  will  be  necessary  to  consider  systematically  the 
changes  observed  at  the  os  uteri,  and  in  so  doing,  to  en- 
deavor to  show  the  relation  of  these  changes  to  the  dis- 
eases of  the  other  portions  of  the  uterus. 

LACER.\TION    OF    THE    CERVIX    UTERI. 

It  not  unfrequently  happens  that  in  the  process  of  partu- 
rition the  uterine  cervix  is  more  or  less  injured,  the  vagi- 
nal portion  being  lacerated  in  various  degrees.  But  it  can- 
not be  said  that  these  lacerations  have  been  considered  as 
constituting  lesions  of  any  considerable  importance  until 
recently.  The  subject  has,  however,  attracted  much  atten- 
tion in  the  United  States  during  the  last  few  years,  and  it 
is  evident  that  the  lacerations  in  question  are  very  impor- 
tant factors  in  the  production  of  diseases  or  discomforts  ref- 
erable to  the  cervical  part  of  the  uterus.  Dr.  Goodell, 
writing  in  1879,  states  that  about  one  sixth  of  the  women 
who  have  had  children,  applying  at  the  University  of 
Pennsylvania  Dispensary,  have  an  ununited  laceration  of 
the  cervix. 

The  second  edition  of  Dr.  Emmet's  valuable  work  con- 
tains a  full  account  of  the  subject,  together  with  the  re- 
sults of  his  own  observations  and  inquiries. 

Since  1862  Dr.  Emmet  has  practiced  an  operation  in  such 
cases.  In  1874  he  published  a  paper  on  "  Lacerations  of 
the  Cervix  Uteri  as  a  frequent  and  unrecognized  Cause  of 
Disease."  Roser,*  it  appears,  first  described  what  he 
termed  "ectropium,"  of  which  there  are  two  forms — one 
arising  from  cicatricial  distortion,  the  other  by  the  crowd- 
ing forward  and  swelling  of  the  mucous  membrane.  Roser 
indicates   as  causes,   excessive   fissures,  also  probably  ob- 

*  "  Archiv.  f,  Heilk.,"  Leipzig,  No.  298. 


DISEASES    OF   THE   OS   AND   CERVIX   UTERI.       417 

Stetrical  incisions  and  gangrenous  destruction  of  the  os 
uteri.  Roser  regarded  many  of  the  cases  of  obstinate  and 
inveterate  hypertrophy  thus  arising  as  incurable;  and  as 
regards  the  cicatricial  ectropium  says,  "  One  will  scarcely 
be  prompted  to  undertake  a  curative  experiment." 

Dr.  Emmet  thinks  the  term  "cicatricial  ectropium"  not 
well-chosen,  for  "the  flaps  in  the  cervix  are  first  rolled  out 
and  forced  apart  from  the  enlarged  uterus  resting  on  the 
floor  of  the  pelvis,  and  this  is  increased  as  the  circulation 
becomes  obstructed,  and  as  the  mucous  follicles  undergo 
cystic  degeneration.     The  condition  at  length  becomes  one 

Fig.  122.* 


of  partial  strangulation,  as  in  paraphymosis."  He  thinks 
the  English  term  better  than  trachelorrhaphy  or  hystero- 
trachelorrhaphy.  Of  500  fruitful  women  who  have  come 
under  his  care  in  private  practice,  32-80  per  cent  who  had 
been  impregnated  and  now  suffered  from  some  form  of 
uterine  disease,  were  found  to  have  laceration  of  the  cer- 
vix. The  injury  on  the  left  side  is  the  most  common,  and 
double  laceration  the  next.  More  than  thirty  per  cent  of 
the  cases  were  attributed  to  tedious  labor.  He  thinks 
rapid  labor  must  be  a  cause  to  a  greater  extent  than  his 
figures  prove.     Sterility  resulted  in   71  "34  per  cent  of  cases 

*  The  drawing  exhibits  results  of  double  lateral  laceration,  showing 
also  enlarged  mucous  follicles.  The  dotted  line  shows  the  outline  when 
the  flaps  are  brought  together  (Emmet). 


41 8  DISEASES   OF   WOMEN. 

where  the  cervix  was  so  injured.  Menstruation  is  in  51 '59 
per  cent  of  cases  increased  (in  length  of  days).  The  occur- 
rence of  cellulitis  in  connection  witli  or  as  a  consequence  of 
laceration  of  the  cervix  is  the  most  important  and  most  fre- 
quent complication.  Thus,  of  the  164  women  last  under 
observation,  ^^,  or  2o'i2  per  cent,  had  cellulitis  at  the  time 
of  the  first  examination. 

The  laceration  is  common,  is  often  overlooked  owing  to 
softness  of  the  parts,  and  it  is  most  common  in  the  middle 
line,  anterior  more  common  than  posterior.  If  in  the  median 
line  and  limited  to  cervix  it  generallj'  heals  rapidly.  It 
may  of  course  pass  into  bladder  and  then  may  leave  fistula. 
Laceration  through  posterior  lip  also  heals  rapidly  and 
may  not  be  suspected  unless  the  inflammation  extends 
sufficiently  into  posterior  ciil  de  sac  \.o  set  up  attack  of  in- 
flammation. If  cellulitis  occurs  at  this  point  it  always  in- 
duces a  most  intractable  form  of  retroversion,  owing  to  the 
formation  of  a  cicatricial  band  felt  as  a  cord.  This  form  of 
laceration  seems  from  the  history  of  the  cases  due  to  "  pos- 
terior occipital  "  position. 

When,  however,  the  laceration  is  in  a  lateral  direction 
and  extends  beyond  the  crown  of  the  cervix,  a  condition 
arises  which  defeats  the  reparative  power  of  nature.  There 
will  exist  a  tendency  for  the  tissues  to  roll  out  from  within 
the  uterine  canal  when  the  upright  position  is  assumed. 
The  lips  are  forced  apart  b)'  the  weight  of  the  uterus  above, 
the  posterior  being  pushed  backward,  the  anterior  forward. 
The  angle  of  tlie  laceration  becomes  the  starting-point  of  an 
erosion,  which  gradually  extends  over  the  everted  surfaces. 
The  involution  is  retarded,  the  erosion  bleeds  readily  as  it 
extends,  and  the  woman  gets  about;  a  profuse  cervical 
leucorrhoea  ensues,  and  the  appearance  of  a  frequent  show 
causes  the  patient  to  seek  relief.  This  laceration  was 
until  recently  universall)^  mistaken  for  ulceration,  and  it 
long  baffled  all  treatment:  improvement  from  rest  was 
followed  by  relapse  on  attempt  at  exercise. 

The  mucous  follicles  of  the  cervix  will  be  found  to  have 
gradually  undergone  cystic  degeneration. 

When  the  laceration  is  double  and  lateral,  the  flapsflatten 
against  the  posterior  wall  of  vagina  or  floor  of  the  pelvis, 
so  that  all  appearance  of  laceration  becomes  lost.  On 
digital  examination  the  cervix  is  found  to  be  larger  than 
the  body  of  the  uterus.  The  relative  size  of  such  a  cervix 
to    the    body   of  the    uterus  is   about    that  of   the    top  of 


DISEASES   OF   THE    OS   AND    CERVIX    UTERI. 


419 


a  half-grown  mushroom  to  its  stem. 
These  flaps  can  be  rolled  in  on 
using  the  speculum  witli  the  patient 
on  the  side,  and  by  seizing  the  an- 
terior and  posterior  lips  of  the  cer- 
vix with  a  tenaculum  in  each  hand. 

There  is  a  variety  when  the  lacera- 
tion is  unilateral,  giving  obliquity 
to  the  uterus. 

Treatment. — Dr.  Emmet  considers 
an  operation  is  required  where  the 
condition  is  evident,  where  enlarge- 
ment of  the  uterus  still  remains,  or 
where  the  woman  suffers  from  neu- 
ralgia. 

T\\&  preparatory  measures  are,  use 
of  vaginal  hot-water  injections,  use 
of  a  pessary  to  lift  uterus  from 
floor  of  vagina,  application  of  tinc- 
ture of  iodine  or  iron  twice  a  week 
with  glycerine  dressings,  and  pled- 
gets of  cotton,  one  before  and  one 
behind,  to  keep  flaps  together.  It 
is  often  necessary  to  puncture  the 
overloaded  cysts  and  so  reduce  the 
strangulation  and  swelling;  iodine 
is  applied  after  this  scarification. 

The  operation  is  best  performed 
with  the  patient  in  the  Sims  posi- 
tion on  the  side.  First  the  flaps 
are  brought  together  by  tenacula. 
Then  the  uterine  tourniquet — Fig. 
123,  a  special  instrument  for  the 
purpose,  constructed  of  a  piece  of 
watch-spring — is  applied,  for  the 
haemorrhage  is  often  excessive. 
Emmet  now  only  uses  it  when 
tissues  are  unusually  soft;  the  use 
of  hot  water  before  the  opera- 
tion renders  it  less  liable  to  occur. 

The  scissors  is  the  instrument 
preferred  to  freshen  the  surfaces. 


Fig.  123.* 


m 


Fig.  123,  watch-spring  tourniquet  used  by  Emmet. 


420 


DISEASES   OF  WOMEN. 


The  uterus  is  drawn  down,  if  possible,  to  outlet  of  vagina 
during  operation.  A  short  i-ound  needle  is  best,  and  wire 
sutures  are  employed  as  shown  in  the  drawing.  The  sutures 
are  removed  in  seven  days.  The  patient  is  kept  in  bed 
for  twelve  days.  The  pessary,  which  is  removed  for  the 
operation,  is  replaced  soon  after  it  is  completed. 

Dr.  Emmet  says  that  the  hypertrophy  and  elongation  of 
cervix  will  almost  invariably  be  found  due  to  laceration  of 
cervix   uteri,  and  the   remedy  is    to  repair   the  laceration. 


Fig.  124.^ 


He  denounces  amputation  with  scissors,  knife,  or  cautery, 
as  malpractice,  and  denounces,  as  most  uncalled  for,  cautery 
or  caustics  to  heal  a  so-called  ulceration.  "Amputation  of 
the  cervix  or  the  repeated  application  to  it  of  cautery  or 
caustics,  will  maim  any  woman  and  most  likely  render  her 
sterile,  and  for  the  want  of  the  support  which  the  cervix 
normally  affords  she  will  be  liable  to  suffer  from  displace- 
ment of  the  uterus. f 

At  the   Cambridge  meeting  of  the   British  Medical  As- 

*  The   drawing  (Fig.  124)  shows  the  shape  of   the  raw  surfaces  after 
denudation  (Emmet), 
f  Op.  cit.,  p.  483. 


DISEASES    OF   THE   OS  AND   CERViX   UTERI. 


421 


sociation,  held  1880,  Dr. 
Montrose  A.  Fallen  of  New 
York  exhibited  instruments 
employed  by  him  in  repair- 
ing the  lacerated  cervix. 
In  his  operation  scissors  of 
various  shapes  are  employed 
to  facilitate  proper  denuda- 
tion. Dr.  Fallen  strenuously 
recommends  the  operation, 
and  expresses  his  conviction 
of  the  necessity  and  advan- 
tages of  the  operation  in 
suitable  cases. 

Looking  over  the  records 
of  my  own  cases,  I  find 
cases  in  which  lacerations  of 
the  cervix  have  been  noted 
as  being  present.  From 
what  I  now  hear  of  the 
cases  related  as  observed 
in  America,  it  seems  evi- 
dent that  in  developing  the 
subject  and  pointing  out 
how  the  lesion  is  to  be  reme- 
died, our  transatlantic  breth- 
ren have  done  a  good  service 
to  gynaecology.  I  believe 
Dr.  Playfair  was  the  first  to 
perform  this  operation  in 
England,  and  he  has  re- 
cently communicated  a  pa- 
{ier  on  the  subject  to  the 
Obstetrical  Society  of  Lon- 
don. I  have  myself  success- 
fully performed  it,  and  have 
come  to  recognize  it  as  a 
most  necessary  and  valuable 
operation. 

[Where  the  cervix  is  much 
engorged  and  very  vascular, 

*  Fig.  125  shows  an  instru- 
ment (reduced  in  size)  made  by 
Meyer  &  ML-!tzer,  admirably  adapt- 
ed for  holding  the  uterus  during 
the  operation. 


Fig.  125. 


S^^ 


422  DISEASES   OF   WOMEN. 

we  are  sometimes  annoyed  at  the  profuse  bleeding  which 
accompanies  the  operation.  Dr.  Clement  Cleveland,  of  New 
York,  has  recently  invented  a  neat  little  double-edged  saw, 
of  which  I  insert  a  wood-cut,  for  use  in  just  such  cases.  It 
cuts  with  the  backward  stroke  only  and  takes  off  the  tissue 
very  neatly.  I  have  used  it  two  or  three  times,  and  like 
its  working.  Of  course  it  is  only  intended  as  an  adjunct 
to  the  scissors,  and  is  not  meant  for  use  in  all  cases.] 

A  severely  lacerated  cervix  implies  a  removal  of  the 
proper  support  to  the  bod}'^  of  the  uterus,  and  dislocation 
of  the  organ  is  no  doubt  favored  thereby.  A  further  effect 
is  the  exposure,  the  friction,  the  irritation  of  the  lining  of 
the  cervix,  resulting  in  abrasion,  bleeding,  hyper-secretion, 
etc.,  of  the  irritated  surface.  It  is  true  that  by  elevating 
the  uterus  the  latter  class  of  evils  is  greatly  lessened;  so 
much  so,  in  fact,  in  many  cases,  that  the  laceration  itself 
becomes,  or  appears  to  become,  a  minor  evil.  Dr.  Emmet's 
account  is  in  conformity  with  this  view  of  the  matter;  and 
it  is  evident  that,  while  considering  it  necessary  to  repair 
the  cervical  laceration,  he  found  it  also  necessary  in  many 
cases,  both  before  and  after  the  operation,  to  sustain  the 
body  of  the  uterus  in  position  by  a  vaginal  pessary. 

An  important  practical  question  is  to  determine  how  far 
eversion  of  the  cervical  mucous  viembrane  is  possible  without 
laceration  of  the  cervix.  It  is  now  perfectly  clear  that  in  a 
considerable  number  of  cases  eversion  arises  in  connection 
with  cervical  laceration,  but  there  can  be  no  doubt  also 
that  very  extensive  eversion  may  occur  without  such  lacera- 
tion. As  a  rule,  in  long-standing  cases  of  acute  flexion, 
there  arises  a  thickening,  swelling,  and  eversion  of  the  os 
uteri  on  the  anterior  or  posterior  aspect,  and  this  ma}-  even 
occur  in  patients  who  have  not  had  children.  Thus,  in  ante- 
flexion cases  the  anterior  side  of  the  os,  in  retroflexion  cases 
tlie  posterior  side,  becomes  swollen  and  the  mucous  mem- 
brane expands.  In  women  who  have  had  children  it  is 
most  liable  to  occur  undoubtedl)',  but  my  observation  en- 
ables me  to  say  that  it  may  occur  even  to  a  considerable 
degree  in  cases  where  there  has  certainly  been  no  lacera- 
tion. 

Hypertrophy,  cystic  degeneration  of  the  lips  of  the  os 
uteri,  eversion  of  the  mucous  membrane,  abrasion  or  ero- 
sion of  the  mucous  membrane  so  everted,  are  all  liable  to 
be  met  with,  and  when  excessive  in  degree  may  be  found 
to  have  originated  in  a  lacerated  cervix,  while  in  other  cases 


DISEASES   OF  THE   OS   AND   CERVIX   UTERI.       423 

they  result  from  long-standing  congestion  of  the  lips  of  the 
OS  uteri,  the  primary  cause  of  which  has  been  a  severe  flex- 
ion of  the  uterus.  In  some  cases  we  find  the  os  uteri  repre- 
sented by  two  rounded  protuberances,  hard  and  firm,  red 
and  angry-looking  on  the  cervical  aspect,  irregular  as  re- 
gards the  surface  from  nodular  swellings  the  result  of 
cystic  degeneration,  and  secreting  freely  a  sanious,  yellow- 
ish fluid.  The  cystic  degeneration,  as  it  has  been  termed, 
appears  to  be  the  result  of  overgrowth  and  distension  of 
the  Nabothian  follicles.  In  process  of  time  the  lips  of  the 
OS  have  become  hypertrophied,  hardened,  and  otherwise 
diseased,  and  the  two  factors  wiiich  singly  or  Jointly  operate 
in  bringing  about  this  state  of  things  appear  to  be  chronic 
flexion  of  the  uterus  and  laceration  of  the  cervix  during 
parturition. 

The  opinion  has  been  expressed  by  more  than  one  author- 
ity in  America  tliat  the  existence  of  laceration  of  the  os 
uteri  constitutes  predisposition  to  cancer  of  the  os  uteri, 
and  that  for  this  reason,  if  for  no  other,  the  lesion  in  ques- 
tion is  one  demanding  operative  interference.  (Further  re- 
marks on  this  subject  will  be  found  in  a  later  chapter,  on 
Cancer  of  the  Uterus.) 

ULCERATIONS   OF    THE    OS    UTERI. 

After  what  has  been  said  in  reference  to  laceration  of  the 
cervix  and  eversion,  due  either  to  this  injury  or  to  the 
existence  of  flexion,  the  consideration  of  the  subject  of 
"ulcerations"  of  the  os  uteri  is  simplified. 

Simple  eversion  of  the  cervical  lining  has  been  frequently 
taken  to  be  "  ulceration."  Dr.  Farre  some  years  ago  *  said: 
"In  the  more  common  degree  of  hypertrophy  with  ever- 
sion, a  crescentic  protrusion  only  of  the  cervical  lining  oc- 
curs. The  unevenness  of  the  surface  caused  by  the  slightly 
swollen  and  prominent  rugae,  and  as  often  by  the  numerous 
little  depressions  consisting  of  enlarged  mucous  crypts,  ac- 
cording as  one  or  the  other  of  these  is  the  predominant 
normal  structure  in  the  cervix,  gives  to  the  part  during  life 
the  appearance  of  a  raw  and  granular  surface,  while  the 
natural  boundary  between  the  lower  edges  of  the  cervical 
canal  and  the  lips  of  the  os  tincae  being  now  transferred 
on  the  latter  in  consequence  of  this  eversion,  an  abrupt  to 

*  "  Cycl.  An.  and  Phys.":  article  Uterus. 


424  DISEASES  OF  WOMEN. 

semicircular  line  becomes  visible,  which,  while  it  only  in- 
dicates the  natural  termination  here  of  the  vaginal  epithe- 
lium, is  frequently  mistaken  for  the  margin  of  an  ulcer." 
The  stretching  of  the  parts,  which  is  sometimes  produced 
by  the  mere  introduction  of  the  speculum,  may  give  rise  to 
this  kind  of  eversion  of  the  lining  of  the  cervix,  whenever 
the  OS  uteri  is  a  little  lax  and  soft,  and  slightly  open. 

Erosions  of  the  everted  cervical  lining  are  not  very  un- 
common, but  they  rarely  pass  into  the  state  of  true  ulcera- 
tion. The  loss  of  tissue  involved  is  generally  merely  re- 
moval of  the  epithelium  of  the  part  affected,  the  vascular 
or  proper  tissues  underneath  being  unaffected.  The  re- 
moval of  the  epithelium,  however,  leaves  the  villi  uncov- 
ered, and  these  are  apt  to  undergo  hypertrophic  changes, 
and  increased  vascularity  also  results.  What  is  termed  a 
"granular"  change  is  sometimes  noticed  in  cases  where 
the  abrasion  or  erosion  has  been  in  existence  for  some 
time.  During  pregnancy,  as  was  observed  by  Cazeaux 
some  3^ears  ago,  the  villi  of  the  cervical  mucous  surface 
undergo  hypertrophic  changes,  and  are  more  vascular  than 
usual.  Moreover,  they  readily  bleed  when  touched,  and 
these  "  physiological  "changes  (for  such  they  are)  must  not 
be  confounded  with  ulceration  or  erosion  produced  by  dis- 
ease. 

Erosions  of  the  everted  cervical  lining  appear  to  be  in 
great  part  due  to  the  friction  of  the  surface  against  the 
vaginal  floor  produced  by  the  movements  of  the  body.  A 
great  secretion  of  fluid  often  occurs  in  cases  of  this  kind, 
the  fluid  being  ichorous,  or  watery,  or  sanious,  according 
as  the  blood-vessels  of  the  exposed  villi  are  lacerated  or 
not.  I  have  observed  a  tendency  to  exfoliation  or  erosion 
of  the  mucous  membrane  at  the  os  externum,  in  cases  of 
chronic  flexion  with  the  retentive  form  of  leucorrhoea. 
Here  the  retained  uterine  secretions  become  irritating,  and 
this  irritation  probably  has  an  eroding  effect  on  the  deli- 
cate mucous  membrane  at  the  os  uteri. 

True  ulcerations  of  the  vaginal  portion  of  the  cervix  uteri 
are  sometimes  met  with.  They  are  generally  associated  with 
enlargement  and  hypertrophy  of  the  cervix  uteri,  whatever 
may  be  the  cause  of  that  enlargement;  or  with  those  affec- 
tions of  the  uterus  usually  classed  under  the  term  "  prolap- 
sus uteri."  They  are  produced  by  the  mechanical  irritation 
to  which  the  prolapsed  cervix  is  exposed,  and  have  all  the 
characters  of  ordinary  ulcerations. 


DISEASES   OF   THE    OS   AND   CERVIX    UTERI.        425 

Another  form  of  ulceration  of  the  os  and  cervix  uteri, 
which  is  rare,  is  by  some  authors  believed  to  be  of  cancer- 
ous nature,  by  others  to  be  of  tuberculous  nature.  Dr.  West, 
in  whose  work*  will  be  found  a  careful  re'sutnc'  oi  what  has 
been  said  by  different  authorities  on  the  subject,  believes 
that  these  intractable  ulcerations  are  instances  of  epithelial 
carcinoma;  and  he  agrees  with  Robin  in  considering  that 
this  kind  of  ulcer  is  to  the  uterus  what  lupus  or  cancroid 
ulcers  are  to  tlie  face.  There  appears  to  be  no  reason,  how- 
ever, why  both  sides  should  not  be  right,  or  for  denying 
that  both  tuberculous  ulcers  of  chronic  nature  and  lupoid 
disease  of  the  cervix  uteri  may  be  witnessed,  though  not  of 
course  in  the  same  individual.  It  can  very  rarely  happen 
that  this  question  will  arise  practically  for  determination, 
these  intractable  ulcerations  being  very  uncommon. 

Syphilitic  Affections^  Ulcerations,  etc. ,  of  the  Os  and  Cervix 
Uteri. — Concerning  true  chancre — primary  syphilitic  ulcer 
— of  this  part,  th.ere  is  but  little  difference  of  opinion.  It 
is  pretty  well  understood  that  it  is  very  rare,  although  it 
has  been  observed.  Chancre  of  the  os  or  cervix  uteri 
presents  an  appearance  like  that  of  chancre  observed  else- 
where; it  is  said  that  there  is  a  greater  disposition  on  the 
part  of  the  ulcers  here  situated  to  bleed.  The  only  con- 
clusive evidence  of  the  nature  of  the  ulcer  would  be  its  re- 
production by  inoculation. 

Respecting  secondary  syphilitic  eruption,  or  ulceration  of 
the  OS  and  cervix,  there  has  been  much  discussion,  nor  is  it 
at  all  settled  how  frequently  ulceration  is  present  in  indi- 
viduals affected  with  secondary  syphilis.  It  does  not  ap- 
pear that  there  is  anything  peculiar  about  the  character  of 
the  ulcerations  present  in  these  cases,  or  which  would  en- 
able us  to  say  at  once  that  such  and  such  an  appearance 
was  due  to  sypliilis.  My  own  observations  induce  me  to 
agree  with  Dr.  Tyler  Smith,  who  held  that  "in  almost  all 
cases  in  which  leucorrhoea  and  disease  of  the  os  and  cervix 
uteri  are  present  in  women  suffering  from  constitutional 
syphilis,  the  uterine  symptoms  are  a  genuine  manifestation 
of  the  constitutional  or  secondary  disorders."! 

The  diagnosis  of  secondary  syphilitic  ulceration  of  the  os 
and  cervix  will  be  materially  influenced  b}'  the  presence  or 
absence  of  a  syphilitic  history  in  the  particular  case,  and 
before  proceeding  to  form  a   decision  on   the  point  all   the 

*  Op.  cit.,  p.  361.  f  "  On  Leucorrhoea,''  p.  gS. 


426  DISEASES   OF   WOMEN. 

antecedents  of  the  patient  must  be  carefully  scrutinized. 
The  effects  of  anti-syphilitic  remedies  would  frequently  as- 
sist us  in  coming  to  a  conclusion. 

Treatment  of  Ulcerations  and  HypertropJiy  of  tJie  Os  Uteri. 
— An  exceedingly  important  element  in  the  treatment  of 
these  cases  is  rest,  and  careful  ablution  at  frequent  intervals 
with  warm  water.  It  frequently  happens  that,  by  these 
measures  alone,  the  size  of  the  os  uteri  is  very  greatly 
diminished  (see  Treatment  of  Congestion  of  the  Uterus, 
page  139),  and  in  all  cases,  whether  subsequently  requiring 
operative  treatment  or  not,  these  measures  may  be  advan- 
tageously cai'ried  out.  Styptic  applications  should  be  sub- 
sequently employed;  and  a  solution  of  nitrate  of  silver,  or 
tannic  acid,  or  dilute  iodine  tincture,  is  useful  in  further 
reducing  the  hypertrophy  (see  page  142). 


CHAPTER   XXX. 

Chronic  Inversion  of  the  Uterus. 

Chronic  Inversion  of  the  Uterus. — Causes,  Effects,  and  Varieties. 
Diagnosis. 

Treatment. — Reduction  by  Systematic  and  Continuous  Pressure  aided 
by  Anaesthesia — Treatment  by  Excision. 

We  are  here  concerned  only  with  cases  of  chronic  inver- 
sion of  the  uterus.  The  consideration  of  the  condition  in 
a  recent  state  belongs  to  the  domain  of  obstetrics  proper. 

Inversion  of  the  uterus  may  occur  during,  or  soon  after, 
parturition,  and  this  is  its  most  frequent  cause;  but  it  may 
occur  also  in  connection  with  the  presence  of  fibroid 
growths — polypi — attached  to  the  internal  surface  of  the 
organ,  and  thereby  distending  it.  It  may  be  partial  of 
complete.  In  its  complete  form  it  may  arise  after  parturi- 
tion; poh'pi  generally  occasion  an  incomplete  form  of  the 
displacement.  When  there  is  complete  inversion,  the  whole 
organ  is  turned  inside  out;  the  uterus  lies  wholly  in  the 
vaginal  canal,  and  in  recent  cases  projects  considerably  out- 
side the  vulva.  When  occurring  in  connection  with  partu- 
rition, the  uterus  gradually  diminishes  in  size,  though  less 
quickly  than  under  ordinary  circumstances,  and  at  the  end 
of  a  few  months  tlie  uterus  may  be  wliollv  within  the  vagina, 
but  completely  inverted. 


CHRONIC   INVERSION   OF  THE   UTERUS.  427 

The  symptoms  and  effects  of  inversion  of  the  uterus  are 
generally  of  a  striking  character,  but  not  invariably  so. 
Haemorrhages,  and  almost  incessant  loss  of  blood  in  smaller 
quantity,  are  usuall)^  observed.  Pains  of  a  dragging  char- 
acter, and  asense  of  great  discomfort  more  or  less  continu- 
ous, are  experienced  by  the  patient,  these  effects  being  not 
seldom  of  a  very  aggravated  character. 

The  patient  frequently  becomes  very  anaemic,  and  there 
may  be  great  general  prostration,  breathlessness,  and  loss 
of  power  of  locomotion,  with  oedema  of  the  lower  extremi- 
ties, etc.  Chronic  inversion  of  the  uterus  may  exist  for 
many  years;  cases  of  twenty-five  or  thirty  years'  duration 
are  well  authenticated. 

In  cases  of  inversion  of  the  uterus  a  tumor  is  felt  occupy- 
ing the  vagina,  which  varies  in  size  according  to  the  degree 
of  the  inversion  and  the  time  which  has  elapsed  since  its 
occurrence.  Tlius,  if  the  inversion  be  recent  and  complete, 
the  tumor  in  the  vagina  may  be  so  large  as  to  project  be- 
yond the  vulva;  but  if  some  weeks  have  elapsed,  it  may  be 
no  larger  than  the  fist,  although  still  complete.  The  tumor 
is  smooth,  uniform,  and  no  opening  is  to  be  detected  on  the 
surface.  On  digital  examination,  it  is  found  that  the  vagina 
terminates  above,  round  the  pedicle  of  the  tumor,  in  a  per- 
fect cul  de  sac,  and  the  surface  of  the  tumor  is  actually  con- 
tinuous with  that  of  the  vagina.  At  the  point  where  the  os 
uteri  should  be  situated  this  pyriform  tumor  projects  down- 
ward into  the  vagina.  The  tumor  itself  is  hard  and  firm, 
and  resistant,  when  the  inversion  has  lasted  a  few  weeks. 
If  the  patient  have  been  recently  delivered,  if  a  tumor  has 
occupied  the  vagina  since  delivery,  and  if,  further,  it  be 
known  that  there  was  no  tumor  previously,  the  diagnosis 
is  not  usually  difficult  to  establish,  provided  the  inversion 
be  complete.  This  statement  is,  however,  not  quite  uni- 
versally true,  for  pregnancy  may  be  associated  with  poly- 
pus, and  the  polypus  may  be  thrust  down  into  the  vagina 
immediately  after  the  expulsion  of  the  child.  Gooch  and 
otliers  have  related  cases  of  this  kind.  There  is  no  possi- 
bility, in  complete  inversion,  of  passing  the  finger  above  the 
pedicle  of  the  tumor,  nor  can  the  uterine  sound  be  made  to 
pass  in  this  direction.  The  symptoms  attending  the  pro- 
duction of  inversion  during  labor  are  characteristic:  exces- 
sive pain — which  may,  however,  be  absent — prostration, 
syncope;  the  uterine  tumor  is  no  longer  felt  above  the 
pubes;  haemorrhage  is  usually  observed.     Inversion   may 


428  DISEASES   OF   WOMEN. 

occur  just  at  the  end  of  labor,  or  a  few  days  after,  from  in- 
cautious exertion  on  the  part  of  the  patient.  Inversion  of 
the  uterus  usually  gives  rise  to  frequent  and  profuse  haemor- 
rhages, together  with  great  discomfort  and  pain;  but  it  does 
now  and  then  happen  that  the  symptoms  are  not  so  urgent 
as  to  attract  much  attention  until  the  disease  has  lasted  for 
some  time.  That  the  symptoms  and  histor}'  of  the  case  are 
not  always  demonstrative  of  its  true  nature,  is  proved  by 
the  fact  that  inversion  of  the  uterus  has  been  frequently 
looked  upon  and  treated  as  polypus. 

With  reference  to  the  diagnosis  of  complete  inversion  fiom 
polypus :  in  both  cases  the  tumor  is  generally  more  or  less 
pyriform;  in  both  cases  it  is  hard,  resistant,  smooth;  in 
both  the  tumor  terminates  above  by  a  constricted  portion; 
in  both  there  are  haemorrhage,  leucorrhoea,  and  symptoms 
produced  by  pressure  on  the  adjacent  viscera;  but  in  the 
case  of  inversion,  neither  the  sound  nor  the  finger  can  be 
passed  upward  beyond  the  pedicle  of  the  tumor,  whereas, 
in  the  case  of  a  polypus  projecting  down  into  the  vagina 
from  the  interior  of  the  uterine  cavity,  an  instrument  can 
be  passed  into  a  cavity  beyond  the  neck  of  the  tumor;  the 
neck  of  the  tumor  being  encircled  by  the  os  uteri,  the  sound 
can  be  made  to  pass  into  the  interior  of  the  uterus.  This 
distinction  is  not  a  perfectly  reliable  one,  for  there  is  occa- 
sionally a  difficulty  in  detecting  tlie  cavity  above  when  it 
really  exists,*  and  sometimes  there  is  found  to  be  adhesion 
of  the  sides  of  the  polypus  to  the  adjacent  wall  of  tlie  vagina 
or  to  the  interior  of  the  cervix  uteri  (West,  Blundell);  and, 
further,  it  may  happen  that  the  polypus  grows  from  a  part 
of  the  uterine  cavity  close  to  the  orifice  (Gooch).  It  is  said 
that  in  cases  of  inversion  the  tumor  is  very  sensible;  that 
this  sensibility  is  wanting  in  cases  of  polypus;  that  the  sur- 
face of  the  inveried  uterus  is  rough,  whereas  the  surface  of 
a  polypus  is  smooth;  but  no  reliance  can  be  placed  on  such 
supposed  distinctions.  If  an  examination  be  made  within 
a  week  after  the  labor,  the  fact  that  tlie  normal  uterine 
tumor  is  absent  from  the  hypogastric  region,  associated 
with  that  of  the  presence  of  a  rounded  firm  tumor  in  the 
vagina,  will  demonstrate  the  nature  of  the  case;  at  a  later 
period  this  remark  would  not  hold  good,  or  at  least  in  the 
same  degree.  Another  mode  of  examination,  enal^ling  us 
to  distinguish  between  inversion  and  polj'pus,  is  the  com- 

*  See  leaned,  1S27-2S,  vol.  i.,  p.  327. 


CHRONIC   INVERSION   OF  THE   UTERUS.  429 

bined  examination  by  the  rectum  and  by  the  bladder — i.e., 
the  finger  introduced  into  the  recturti  and  a  sound  into  the 
bladder,  by  which  means  an  absence  of  the  body  of  the  uter- 
us from  its  normal  position  can  be  substantiated  (Arnott). 

In  cases  of  pa>-iial inversion  of  the  uterus  the  difficulties  as 
regards  the  diagnosis  are  more  considerable  than  when  the 
inversion  is  complete.  Here  the  pedicle  of  the  tumor  is  en- 
circled by  the  os  uteri,  as  observed  when  a  polypus  projects 
downward  from  the  uterus  into  the  vagina.  In  cases  of 
partial  inversion,  however,  the  sound  cannot  be  passed  so 
far  beyond  the  encircling  band  formed  by  the  os  uteri  as 
usual,  whereas  in  cases  of  polypus  the  cavity  may  be  even 
longer  than  ordinary.  A  complex  condition  has  been  now 
and  then  observed,  in  which  the  diagnostic  mark  alluded 
to  might  fail;  that,  namely,  in  which  there  is  a  polypus  of 
the  uterus  forming  the  lower  part  of  the  tumor,  this  tumor 
having  dragged  down  the  fundus  uteri  with  it  and  produced 
partial  inversion,  where,  in  fact,  the  two  conditions,  polypus 
of  the  uterus  and  inversion  of  the  uterus,  are  associated. 
Dr.  McClintock*  has  directed  attention  to  a  new  diagnostic 
sign  of  the  presence  of  inversion.  It  is  this:  When  the  case 
is  one  of  inversion,  on  drawing  the  tumor  downward  the 
lip  formed  by  the  os  disappears;  on  ceasing  this  traction 
the  lip  is  again  evident.  A  very  careful  consideration  of 
the  previous  history,  combined  with  examination  of  the 
parts,  are  necessary  to  come  to  a  correct  conclusion  in  these 
doubtful  cases.  The  tumor  due  to  a  partially  iaverted 
uterus  is  hard  and  firm,  like  a  fibrous  polypus;  the  symp- 
toms produced  by  it  are  pretty  much  the  same — haemor- 
rhages, discharges,  etc. — but  there  is  more  pain,  more  dis- 
comfort to  be  looked  for  in  the  case  of  inversion  than  when 
there  is  only  a  polypus  present.  Again,  the  double  exam- 
ination by  the  rectum  and  bladder  is  very  important  in  as- 
sisting the  diagnosis,  the  more  so  as  in  cases  of  poh^pus 
partly  projecting  from  the  os — the  particular  cases,  in  fact, 
which  most  closely  simulate  this  partial  inversion  of  the 
uterus — the  body  of  the  uterus  is  generally  more  or  less 
enlarged,  owing  to  the  presence  of  the  polypus  within  it. 

TREATMENT. 

There  has  been  usually  found  but  little  difficulty  in  re- 
placing an  inverted  uterus  when  the  condition  has  been  de- 

^  Op.  cit.,  p.  91, 


430  DISEASES   OF   WOMEN. 

tected  at  once,  as  in  the  process  of  labor.  Wlien,  however, 
the  disease  is  a  chronic  one,  the  difficulties  to  be  encoun- 
tered are  great.  We  must  first  speak  of  the  treatment  of 
cases  of  chronic  inversion  of  the  uterus  of  the  simple  and 
uncomplicated  kind. 

Formerly  these  cases  were  only  treated  by  excision;  the 
patient  was  relieved  of  the  tumor  and  of  her  troubles  by 
means  of  the  knife,  at  the  expense  necessarily  of  loss  of  all 
power  of  bearing  children  subsequenth',  and  not  unfre- 
quently  at  the  expense  of  loss  of  life  altogether.  Happily 
art  has  stepped  in  to  the  rescue  of  these  cases,  and  a  method 
has  obtained  general  adoption  in  the  profession,  by  means 
of  which  the  normal  shape  of  the  uterus  is  restored,  even 
in  long-standing  cases.  M.  Valentin,*  in  1847,  reduced  an 
inverted  uterus  after  the  lapse  of  upward  of  a  year  from  the 
date  of  its  occurrence.  The  reduction  was  performed  by 
the  aid  of  the  two  hands,  the  left  placed  over  the  hypogas- 
tric region,  the  right  in  the  vagina,  the  tumor  being  grasped 
by  the  finger  and  thumb  of  the  right  hand.  These  manip- 
ulations were  performed  while  the  patient  was  under  the 
influence  of  ether;  and  after  application  of  continuous 
pressure  in  this  way  for  about  ten  minutes  the  reduction 
was  accomplished,  and  the  patient  completely  cured.  The 
etherization  in  this  case  enabled  the  patient  to  bear  the 
operation,  it  having  been  relinquished  previously  owing  to 
the  great  pain  produced.  Mr.  Canney,f  of  Bishop  Auck- 
land, reduced  a  ciironic  case  of  inverted  uterus  of  five 
months'  duration,  in  1852,  under  the  influence  of  chloroform, 
and  by  manipulations  pretty  much  the  same  as  those  de- 
scribed above.  M.  Barrier's  |  case,  also  in  1852,  is  the  next 
reported,  the  duration  having  been  considerable.  These 
three  cases  had  escaped  my  notice  in  preparing  the  first 
edition  of  this  work.  Dr.  Tyler  Smith,  §  in  1856,  success- 
fully reduced  an  inverted  uterus  of  twelve  years'  duration 
after  several  days'  treatment,  the  uterus  being  pressed  and 
moulded  by  the  fingers  for  about  ten  minutes  night  and 
morning.  After  repeated  trials,  the  cervix  uteri,  which  was 
firmly  contracted  round  the  neck  of  the  projecting  tumor, 
began  to  yield  a  little,  and  the  tumor  could  be  slightly  sunk 
in  the  os.     After  each  operation,  a  large  india-rubber  air- 

*  Quoted  from  Gaz.  M/d.  in  Ranking's  "Abstracts."  vol.  vii. 
I  Ranking,  vol.  xvi.  %  Ibid. 

§  "  .Medico  Chir.  Trans.,"  vol.  xlii.,  p.  183. 


CHRONIC   INVERSION    OF   THE    UTERUS.  43 1 

pessary  was  placed  in  the  vagina,  and  inflated  to  as  great 
an  extent  as  the  patient  could  bear.  The  air-pessary  was 
worn,  with  few  exceptions,  day  and  night.  "After  more 
than  a  week  of  these  proceedings,"  says  Dr.  Tyler  Smith, 
the  patient  felt  a  good  deal  of  pain  through  the  whole  of 
one  night;  and  in  the  morning,  when  an  examination  was 
made,  it  was  discovered  that  complete  reinversion  had  taken 
place.  A  small  air-pessary  was  afterward  worn  for  a  few 
(lays,  and  the  recumbent  position  maintained.  Subsequent- 
ly the  patient  became  pregnant. 

The  principle  of  the  successful  reductions  effected  in  ob- 
stinate cases  is  to  maintain  a  persistent  pressure  on  the 
inverted  part,  or  rather  a  combination  of  moulding  and 
pressure  by  means  of  the  fingers  and  thumb  introduced  into 
the  vagina,  counter-pressure  being  applied  externally,  and 
when  this  does  not  succeed,  to  apply  a  more  continuous 
but  less  forcible  pressure  by  means  of  an  india-rubber  air- 
pessary.  The  part  which  has  been  inverted  last  should  be 
l^ushed  upward  first,  as  Dr.  McClintock  has  very  properly 
remarked.  The  uterus  is  capable  of  being  readily  moulded, 
and  on  this  property  of  the  uterus  our  attempts  are  to  be 
based;  sudden,  too  forcible,  and  too  abrupt  manipulations 
must  be  avoided.  Chloroform  or  ether,  as  the  reports  show, 
are  invaluable  adjuncts  in  the  treatment. 

Dr.  Marion  Sims  proposed,  in  difficult  cases,  to  make  a 
vertical  incision  through  the  uterine  tissues  on  each  side,  at 
the  part  corresponding  to  the  os  uteri,  so  as  to  allow  more 
easily  of  the  reduction  of  the  tumor.  Dr.  Barnes*  also 
performed  an  operation  on  this  principle  successfulh'.  The 
case  was  one  of  some  months*  standing,  where  continuous 
pressure  had  failed.  He  drew  down  the  uterus  and  made 
three  vertical  incisions.  The  uterus  was  at  once  reduced 
by  taxis,  and  the  case  did  well.  He  recommended  that  in 
future  two  incisions  only  should  be  made,  and  that  contin- 
uous elastic  pressure  (by  water-bags)  should  be  employed 
to  restore  the  inverted  uterus. 

Dr.  Emmet's  method  of  reduction  is  as  follows: 

With  one  hand  in  the  vagina,  the  fundus,  in  the  palm  of 
the  hand,  is  firmly  grasped  and  pushed  upward,  the  fingers 
then  immediately  separated  to  the  utmost;  at  the  same  time 
the  other  hand  is  emploj'ed  over  the  abdomen  in  the  at- 
tempt to  roll  out  the  parts  forming  the  ring  by  sliding  the 

*  "  Med.  Chir.  Trans.,"  vol.  liii. 


432  DISEASES   OF   WOMEN. 

abdominal  parietes  over  its  edge.  This  process  is  contin- 
ued some  time,  and  later  on  the  tips  of  the  fingers  are  used 
to  complete  the  re-inversion.  Dr.  Emrnet  has  also  em- 
ployed sutures  for  closing  the  lips  over  the  fundus  after  a 
partial  reduction,  to  preserve  temporarily  the  advantage 
gained.* 

In  Dr.  Emmet's  operation  an  important  element  is  the 
application  of  counter-pressure  over  the  uterus  from  above, 
and  the  taxis  performed  in  this  way  has  proved  very  suc- 
cessful in  his  hands.  Dr.  Tate,  of  Cincinnati,!  records  an 
interesting  case  where  counter-pressure  was  made  above 
by  two  fingers  carried  up  in  the  rectum,  the  fundus  being 
then  pushed  up  by  the  two  thumbs.  As  this  procedure 
tired  the  hands,  the  urethra  was  dilated  and  one  finger  of 
the  other  liand  inserted  so  as  to  get  counter-pressure  in 
front  as  well  as  behind.  The  reduction  was  finally  effected 
by  pressure  from  a  stem  placed  below  instead  of  the  two 
thumbs.     Silver  wires  were  placed  in  the  os  for  three  davs. 

Dr.  Jas.  P.  White  states  that  his  experience  is  that  "well- 
directed  pressure  upon  the  fundus,  if  continued  longenough, 
will  in  all  cases,  unless  prevented  by  firm  adhesions,  result 
in  restoration  or  reposition,  no  matter  how  much  time  may 
have  elapsed  since  inversion  has  occurred."  J 

His  method  of  reduction  is  as  follows:  The  operator 
kneels  on  the  ground,  the  patient  is  placed  on  the  back  at 
the  edge  of  the  bed,  anaesthetized.  The  uterus  is  then 
manipulated  by  the  right  hand  introduced  into  the  vagina 
entirely.  The  hand  grasps  the  uterus  and  presses  upon  the 
tumor;  at  the  same  time  Dr.  White's  apparatus  is  brought 
into  play.  It  consists  of  a  hard  rubber  cup  and  stem,  the 
latter  a  little  curved;  the  stem  ends  externally  in  a  pyra- 
midal-shaped spiral  spring  of  steel  wire.  The  cup  is  placed 
against  the  fundus  uteri,  the  base  of  the  spring  against  the 
breast  of  the  operator.  The  left  hand  of  the  operator  is 
used  to  make  counter-pressure  on  the  upper  part  of  the 
uterus  through  the  abdominal  walls. 

Dr.  White  relates  three  typical  cases,  of  six  months',  three 
years',  and  twenty-two  years'  duration  respectively;  in  the 
last  case  reduction  was  effected  in  less  than  two  hours.. 
Dr.  White  says  he  has  performed  the  reduction  successfully 
in  this  way  in  nine  other  cases. 

*  Op.   at.  (2d  edit.),  p.  424. 

■|  Cincinnati  Lancet  and  Observer,  March,  1878. 

\  "  Transactions  of  Philadelphia  Medical  Congress,"  1876. 


CHRONIC  INVERSION   OF   THE   UTERUS. 


433 


The  more  recent  experience  of  various  operators  would 
seem  to  be  in  favor  of  reduction  of  the  inverted  uterus  by 
a  process  of  continuous  elastic  pressure  spread  over  some 
•  ittle  time,  in  preference  to  a  more  rapid  and  summary 
method  of  procedure.  And  various  methods  have  been 
successfully  adopted  of  applying  such  continuous  elastic 
pressure. 

Fig.  126.* 


Thus  Dr.  Barnes  used  a  stem  iMovidcd  with  an  elastic 
cap  for  the  purpose  of  keeping  up  the  pressure.  (This  was 
employed  after  incising  the  os  uteri  at  two  or  three  points 
in  its  circumference  so  as  to  relax  or  weaken  the  constric- 
tion: incisions  one  third  of  an  inch  deep  and  two  thirds  of 
an  inch  long.) 


*  White's  method. 


434 


DISEASES   OF   WOMEX. 


Mr.  Lawson  Tait  has  employed  a  stem  with  a  cup-sliaped 
end,  six  inches  long,  and  pressure  is  made  by  means  of 
elastic  ligatures  fixed  to  the  stem  outside  the  vagina  and 
attached  to  a  band  round  the  waist. 

Dr.  Aveling  *  has  improved  the  stem  used  as  above  by 
giving  it  an  external  perineal  curve.  Dr.  John  Williams 
records  a  case  thus  treated:  a  cup  of  vulcanite  was  mounted 
on  a  metallic  stem  having  a  perineal  curve,  and  to  it  affixed 
four  elastic   bands,  two  carried   in   front  and   two  behind. 

Fig.  127. +■ 


At  the  end  of  twenty  hours  removed,  partial  re-inversion 
having  been  effected.  The  instrument  re-applied  and  bands 
tightened,  and  after  another  twelve  hours  the  operation 
completed.  In  this  case  the  inversion  was  of  two  years  and 
four  months'  duration.  Dr.  Aveling  records  two  cases  of 
his  own,  and  states  that  the  average  time  occupied  in  three 
cases  in  reducing  the  uterus  was  forty  hours  only. J  A  case 
of  inversion  is  recorded  by  Dr.  Gervis.^  treated  in  a  similar 

*  "  Obst.  Journ.,"  Ix.xiii.,  p.  21. 

f  Fig.  127  shows  the  shape  of  Dr.  Aveling's  instrument;  the  line  A  B 
the  direction  of  the  pressure. 

I  Rrit.  M,\i.  Journ.,  Sept  6,  1S79.     §  "  Obst.  Journ."  Ixxx.,  p.  373. 


CHRONIC   INVERSION   OF   THE    UTERUS. 


435 


way  after  other  methods  had  been  only  partially  successful. 
Dr.  Wing,  of  Boston,  U.  S.  of  America,  reports  a  case  of 
fi^urteen  months'  standing  cured  in  three  days  b}'  the  above 
method. 

Reduction  after  Abdominal  Section. — Dr.  Thomas, of  New 
York,  performed  a  remarkable  operation  in  an  obstinate 
case.  He  cut  into  the  abdomen,  dilated  \.\\e.cul  de  sac oi  tlie 
uterus  from  within  the  abdomen,  by  a  steel  dilator,  and  thus 


vl 

X 


/ 


,/^  /-^^^ 


^^fe^ 


Jei^ 


reduced  the  inveisiu;.  ,  >  ...c  taxis.  Recovery  followed. 
Previously  the  pressure  and  incision  method  had  failed. 
In  three  other  cases,  by  ingenious  variations  of  the  pressure 
treatment,  Dr.  Thomas  succeeded  in  restoring  the  uterus. 
The  treatment  of  cases  of  inversion  of  the  Jiteriis  associated 
wit/i polypus  of  the  I. terus  requires  a  few  words.  When  the 
polypus  has  a  large  basis   of  attachment,  the  fundus  may 

*  Fig.  128,  from  a  preparation  in  University  College  Museum,  repre- 
sents inversion  associated  with  a  large  polypoid  tumor.  The  tumor  has 
produced  complete  inversion  of  the  uterus  and  of  the  vagina. 


436  DISEASES   OF  WOMEN. 

be  so  drawn  downward  that  what  appears  to  be  the  pedicle 
of  the  polypus  is  really  the  uterus  itself.  Thus  a  specimen 
was  exhibited  at  the  Pathological  Society,  and  referred  to 
Dr.  Marion  Sims,  Dr.  John  Ogle,  and  myself,  for  examina- 
tion, in  which  such  a  tumor  had  been  excised,  and  a  cir- 
cular piece  comprising  the  fundus  uteri  had  been  removed 
with  it.*  The  case  shows  the  necessity  for  great  caution 
in  excising  tumors  projecting  through  the  os  uteri.  In 
most  cases  where  a  polypus  projects  into  the  vagina  from 
the  uterus,  it  draws  down  the  wall  of  the  uterus  a  little, 
and  when  the  pedicle  is  broad  this  partial  inversion  of  the 
uterus  is  more  likely  to  be  extensive.  The  use  of  the  sound 
would  in  such  cases  give  valuable  information. 


CHAPTER    XXXI. 

Prolapsus  of  the  Uterus. 

General  Remarks  on  the  Pathology  of  the  Subject — Mechanism  by 
which  the  Uterus  is  kept  in  its  Place — The  various  Conditions  present 
in  Cases  of  Prolapsus — Illustrations  of  various  Conditions  and  Com- 
plications— Mechanism  of  the  Process — Relation  to  Cystocele,  Recto- 
cele,  and  Fle.\ions — Hypertrophic  Elongation  of  the  Cervix  and  its 
Varieties — Symptoms  and  Progress  of  Prolapsus. 

Dl^gnosis. 

Treatment. — Must  be  adapted  to  the  Peculiarities  of  the  Case — Treat- 
ment of  Prolapsus  from  Hypertrophy  of  the  Cervi.\ — Excision  of  the 
Part — Other  Forms  of  Prolapsus — Measures  directed  (i)  to  the  Condi- 
tion of  the  Uterus;  (2)  to  the  Condition  of  the  Uterine  Supports — Arti- 
ficial Means  for  maintaining  the  Uterus  in  its  proper  Place  in  the  Pel- 
vis, by  Pessaries,  by  external  Appliances,  by  Constriction  of  the  Vag- 
inal Aperture,  or  the  Canal  itself — Description  of  various  Operative 
Procedures. 

Prolapsus,  or  falling  of  the  womb,  is  an  affection  to  which 
women  are,  in  one  form  or  other,  exceedingly  liable,  and  it 
is  one  which  is  not  unfrequently  productive  of  very  much  in- 
convenience and  distress.  Intimately  connected  as  the  uterus 
is  with  the  adjacent  organs,  its  displacement  downward  is 
almost  necessarily  attended  with  more  or  less  displacement 
of  these  organs  also.  Prolapsus  of  the  uterus,  then,  is  rarely 
a  simple  affection;  and,  for  this  reason,  it  will  be  convenient 

*  "Trans,  of  the  Pathological  Society,"  vol.  xvi.,  p.  210. 


Prolapsus  of  the  uterus.       437 

to  consider  together  the  various  displacements  associated 
more  or  less  frequently  with  it,  viz.,  prolapsus  of  the  uterus, 
prolapsus  of  the  bladder  (cystocele),  prolapsus  of  the  va- 
gina, and  prolapsus  of  the  rectum  through  the  vagina  (rec- 
tocele). 

The  term  "  prolapsus"  is  in  this  country  generally  used 
to  designate  all  grades  of  the  displacement.  In  America  it 
appears  that  ''prolapsus"  means  falling  of  the  womb  within 
the  vagina,  while  "  procidentia"  is  used  to  designate  its  ap- 
pearance externally  to  the  vaginal  aperture.  In  this  place 
one  term — prolapsus — will  be  applied  to  both  these  contli- 
tions. 

The  anatomical  relations  and  connections  of  the  uterus 
are  of  the  utmost  importance  in  all  that  concerns  a  right 
understanding  of  the  subject  of  prolapsus.  The  uterus  is 
supported  by  a  complex  mechanism,  the  various  parts  of 
which  are  mutually  dependent,  and  a  failure  or  weakening 
of  one  leads  to  derangement  of  the  others.  It  frequently 
requires  no  little  attention  to  ascertain  where  the  "break- 
down," literally  as  well  as  figuratively,  first  happened;  but 
unless  the  investigation  be  successful,  we  can  have  no  true 
basis  for  our  curative  efforts. 

Natural  Supports  of  the  Uterus. — In  a  former  chapter,  the 
structures  by  which  the  uterus  is  retained  in  its  place  have 
been  described,  but  principally  in  reference  to  the  preven- 
tion of  what  have  been  termed  the  minor  displacements  of 
the  uterus  (see  p.  167).  We  have  now,  however,  to  consider 
how  far  these  natural  supports  of  the  uterus  prevent  those 
further  and  more  severe  displacements  which  come  properly 
under  the  head  of  prolapsus  or  procidentia  of  the  organ. 
The.  peritofieuiii  SQVwcs  little  purpose  in  restraining  the  down- 
ward movement  of  the  uterus.  The  round  ligament  has  an 
influence  Vv'hich  is  exerted  for  the  most  part  in  restraining 
the  movement  of  the  fundus  backward.  Still  in  a  case 
where  the  uterus  had  descended  a  little,  it  would  aid  in 
preventing  further  descent.  The  utero-sacral  ligatnents  are 
so  placed  as  directly  to  prevent  falling  of  the  uterus.  They 
are  firm,  fibrous  bands,  passing  one  on  each  side  straight 
between  the  cervix  uteri  and  the  sacrum.  Dr.  Farre  justly 
drew  attention  to  the  importance  of  these  ligaments.  The 
broad  ligaments — not,  properly  speaking,  ligaments,  being 
simply  the  mesentery  of  the  Fallopian  tubes — have,  in  the 
early  stage  of  prolapsus,  little  restraining  effect  as  regards 
descent  of  the  uterus,  but  they  would  necessarily  assist  in 


438 


DISEASES    OF   WOMEN. 


checking  its  further  progress  downward.  The  uiero-vesical 
ligaments  connect  the  uterus  very  closely  with  the  bladder, 
and,  supposing  the  distended  bladder  to  be  fixed,  it  would 

Fig.  129. 


be  almost  impossible  for  the  uterus  to  descend  below  its 
proper  level  in  the  pelvis.  The  bladder,  however,  is  not  so 
fixed.  A  movement  of  the  whole  bladder  downward  neces- 
sarily carries  with  it  the  uterus,  and  correspondingly  the 
uterus  cannot  descend  without  carrying  with  it  that  per- 


PROLAPSUS  OF  THE  UTERUS.         439 

tiori  of  the  bladder  with  which  it  is  connected,  viz.,  the  pos- 
terior part.  Lastly,  the  general  connections  of  the  uterus 
with  the  adjacent  parts,  and  constituted  by  a  verj'  consid- 
erable quantity  of  blood-vessels  and  connective  tissue,  form, 
as  Dr.  Savage*  has  shown,  a  very  important  additional  ap- 
paratus for  restraining  undue  mobility  of  the  uterus.  Dr. 
West  considers  that  the  canal  of  the  vagina  contributes  very 
much  to  supporting  the  uterus  in  proper  position.  The  re- 
searches of  Mr.  D.  B.  Hart,  referred  to  at  p.  169,  explain 
how  the  vagina  prevents  prolapsus  of  the  uterus,  and  the  im- 
portance of  the  firm  support  which  the  normal  perineum 
gives  to  the  floor  of  the  vaginal  canal. 

In  his  eleventh  plate, f  Dr.  Savage  has  delineated  experi- 
mental observations  ^post  mortem)  on  the  ligaments  of 
the  uterus  and  the  resistance  they  offer  to  descent  of  the 
organ.  Moderate  traction  on  the  uterine  cervix  by  a  vul- 
sellum  was  found  to  compress  the  bladder  against  the  pel- 
vis, to  straighten  and  put  on  the  stretch  the  utero-sacral 
ligaments,  to  curve,  but  not  to  stretch,  the  round  ligament. 
Cutting  through  the  utero-sacral  ligaments  allowed  the 
uterus  to  descend  still  lower,  until  the  os  uteri  was  just 
outside  the  vagina:  the  results  were  that  the  bladder  was 
drawn  down  closely  following  the  uterus,  the  rectum  not 
disturbed,  the  broad  ligament  now  for  the  first  time  put  on 
the  stretch.  Dividing  the  broad  ligament  allowed  of  the 
further  descent  of  the  uterus  to  the  extent  of  an  inch:  but 
the  sub-peritoneal  pelvic  cellular  tissue,  particularly  where 
it  surrounded  the  uterine  blood-vessels,  and  where  it  was 
strengthened  by  additional  trabecular  filaments,  was  found 
to  restrain  further  descent  of  the  organ.  Complete  pro- 
lapsus was  produced  on  the  yielding  of  the  pelvic  reflex- 
ions of  the  broad  ligament.  The  round  ligament  was  last 
put  on  the  stretch. 

The  perineum  is  undoubtedly  a  most  important  struc- 
ture in  relation  to  the  prevention  of  complete  or  partial 
uterine  prolapsus  and  procidentia.  This  has  been  forcibly 
put  forward  by  Dr,  Thomas  in  his  last  (1880)  edition,  and 
Mr.  D.  B.  Hart's  views  are  in  accordance  therewith.  Dr. 
Thomas,  in  his  latest  edition,  gives  drawings  exhibiting  the 
shape   and    size  of   the  perineum   to  illustrate   his  views. 

*  "  Illustrations  of  the  Surgery  of  the  Female  Generative  Organs,"  1863. 
Plate  IX. 
t  Op.  at. 


440  DISEASES   OF  WOMEN. 

He  regards  the  perineum  in  the  normal  state  as  a  concavo-- 
convex triangle,  anteriorly  supporting  the  inferior  wall  of 
the  vagina,  while  its  posterior  side  supports  the  anterior 
wall  of  the  rectum.  The  accompanying  drawing  (Fig. 
129)  is  one  published  by  myself  in  the  "  Mechanical  System 
of  Uterine  Pathology"  two  years  ago,  and  the  shape  and 
size  of  the  perineum  here  shown  is  closely  in  conformity 
with  that  represented  by  Dr.  Thomas  in  his  lately  published 
work. 

The  foregoing  suggests  valuable  inferences  regarding  the 
controlling  powers  ^//^<z^  simple  descent  of  the  uterus;  but 
it  must  be  recollected  in  applying  these  inferences  that  they 
suppose  a  pre-existent  normal  condition  (and  I  would  in- 
clude shape)  of  the  uterus  itself. 

In  point  of  fact  prolapsus  of  the  uterus  is  a  complex 
event.  It  is  impossible,  moreover,  to  consider  prolapsus 
apart  and  separate  from  the  subject  of  flexions;  from  an 
etiological  point  of  view  at  least.  I  have  already  discussed, 
under  the  head  of  Flexions,  the  mechanism  of  those  changes 
in  the  shape  of  the  organ,  and  the  relation  of  the  uterine 
ligaments  to  flexions.  We  have,  therefore,  now,  amongst 
other  things,  to  discuss  the  relation  between  flexions  and 
prolapsus  in  its  various  forms  and  degrees. 

There  are  two  principal  elements  in  existence  in  every 
case  of  prolapsus,  sometimes  separately,  sometimes  con- 
jointly. 

These  are — (i)  increased  weight  or  altered  shape  of  the 
uterus;  (2)  impairment  or  destruction  of  the  supporting 
structures  below  the  uterus.  The  foregoing  classification 
will  not  include,  of  course,  every  imaginable  case:  for 
instance,  hypertrophic  growths  downward  from  the  cervix 
uteri. 

The  relation  between  the  various  casual  elements  inordi- 
nary cases  is  most  easily  illustrated  by  descriptions  of  ac- 
tual cases. 

Thus — (a)  During  a  labor  the  perineum  is  torn,  the  vag- 
inal aperture  increased  in  size;  the  floor  of  the  bladder, 
not  so  well  supported  as  it  should  be,  comes  to  occupy  a 
position  nearer  the  ostium  vaginae  than  usual.  Slight  ex- 
ertion increases  this  descent  of  the  bladder,  the  uterus  fol- 
lows it,  and  soon  comes  to  take  a  position  lower  in  the 
pelvis  than  usual. 

Or  {!?)  concurrently  with  such  enlarged  perineal  aper- 
ture the  patijsnt  is  the  subject  of  defective  involution  of  the 


PROLAPSUS   OF   THE   UTERUS. 


441 


Uterus.  She  moves  about  too  soon  after  labor,  the  uterus 
becomes  first  a  little  anteverted,  then  anteflexed;  and  the 
bladder,  less  supported  than  usual  below  and  more  pressed 
upon  from  above,  gives  wa}'.  The  result  is,  perhaps,  con- 
firmed anteflexion  and  cystocele. 

A  further  stage  may  be  witnessed,  after  the  lapse  of 
many  years  as  a  rule,  viz.,  complete  descent  of  the  whole 
uterus  external  to  the  vulva. 

Or  (r)  the  patient  is  unmarried.  Anteflexion  of  the 
uterus  exists.     The   bladder  is  slowly  pushed  downward, 

Fig.  130.* 


and  spite  of  the  uninjured   ostium    vaginae  it   is  gradually 
protruded. 

Or  (d)  the  patient  has  shortly  after  labor  acquired  a 
retroflexion  of  the  uterus.  The  labor  has  been  attended 
with  laceration  of  the  perineum  also.  Soon  the  uterus 
falls  lower  in  the  pelvis,  the  retroflexion  becoming  at  the 
same  time  intensified,  and  first  of  all  the  posterior  vaginal 
wall  is  protruded  at  the  vaginal  aperture  (rectocele),  then 
follows  the  fundus  of  the  uterus.     At  a  later  stage  of   the 


*  Fig.  130  represents  a  case  in  University  College  Hospital,  set.  42. 
The  patient  had  had  two  children — the  last  nineteen  years  ago.  The 
case  was  cured  by  operation. 


442        ^  DISEASES  OF  WOMEN. 

affection  the  whole  uterus  may  pass  outside  the  vulva,  re- 
maining still,  however,  retroflexed  (see  Fig.  130). 

Or  (e)  the  lower  part  of  the  uterus  becomes  elongated, 
the  effect  being  that  the  cervix  of  the  uterus  finally  becomes 
external  to  the  vulva,  bringing  with  it  the  bladder  more  or 
less  completely.  These  constitute  a  class  by  themselves, 
and  will  be  presently  more  fully  described. 

These  illustrations  might  be  easily  increased  in  number. 

The  foregoing  illustrations  are  put  forward  with  the 
view  of  showing  the  various  "  first  steps,"  as  they  may  be 
termed,  toward  prolapsus.  Occupation  and  age  are  two  ele- 
ments of  considerable  importance  in  altering  the  character 
of  the  prolapsus  in  different  cases.  An  occupation  involv- 
ing much  standing  is  certainly  provocative  of  its  occur- 
rence in  a  very  marked  degree.  And  as  age  advances,  if 
the  quantity  of  fat  in  the  body  diminishes,  the  uterus  is 
more  apt  to  descend  than  it  was  before. 

Violent  strains  are  evidenth^  capable  of  producing  pro- 
lapsus instantaneously,  even  when  the  parts  are  previously 
healthy  and  parturition  has  not  occurred;  but  ordinarily  the 
action  of  strains  is  more  indirect,  the  first  effect  being  to 
produce  a  liexion,  which  fiexion  is  the  starting-point,  end- 
ing finally  in  prolapsus.  Flexions  bring  about  prolapsus 
very  frequently  in  the  following  manner:  The  process  of 
defaecation  is  impeded  by  the  fiexion;  the  patient  finds  it 
necessary  to  strain  very  much  to  procure  an  evacuation; 
the  whole  pelvic  contents  are  thus  pressed  downward;  the 
supports  of  the  uterus  stretched;  the  fiexion  intensified;  and, 
by  and  by,  the  uterus  itself  escapes  from  the  vulva. 

Cystocele  is  observed,  as  already  hinted  at,  chiefly  in  as- 
sociation with  a  ruptured  perineum  and  an  antefiexed 
uterus,  but  it  may  occur  apart  from  such  injury  of  perine- 
um, and  in  women  who  have  had  no  children.  Here  the 
tumor  which  forms  at  and  protrudes  from  the  vulva  is 
small  and  readily  reduced.  Cystocele  is  also  witnessed 
when  the  cervix  uteri  descends  externally.  This  remark 
applies  to  that  part  of  the  cervix  which  is  connected  so  in- 
timately with  the  bladder,  and  when  this  part  of  the  cer- 
vix descends  the  bladder  must  come  with  it.  When  the 
whole  uterus  is  outside  the  vulva,  there  must  therefore  be 
a  considerable  portion  of  the  bladder  protruded  externally. 
But  when  the  part  of  the  cervix  behm'  the  vaginal  reflexion 
is,  as  sometimes  happens,  alone  hypertrophied,  and  pro- 
jects downward,   perhaps   in  a  conical  form,    through  the 


PROLAPSUS   OF   THE    UTERUS. 


443 


vulva,  there  is,  under  these  circumstances,  no  necessity  for 
a  simultaneous  descent  of  the  bladder,  and  such  cases  are 
not  usually  complicated  with  cystocele. 

Cystocele,  though  ordinarily  not  attended  with  more  than 
discomfort  when  slight  in  degree,  is  liable  to  become  a 
condition  of  torture  to  the  patient.  Thus  a  married  woman 
just  over    forty,   who  had    never    had  children,  presented 


Fig.  131.^ 


herself  for  treatment  at  University  College  Hospital. 
There  was  a  tumor  the  size  of  one  end  of  a  hen's  egg  pro- 
truding, and  composed  of  the  bladder.  It  was  sensitive  to 
such  a  degree  tliat  the  slightest  touch  gave  excruciating 
pain.  The  tumor  could  not  be  kept  up,  intercourse  had 
not  been  possible  for  years,  and  various  means  had  been 
tried    to    relieve    her  ;  amongst  other  things,  an  operation 

*  Fig  131  represents  anteflexion  associated  with  cystocele.  The  case 
is  the  one  described  in  the  text,  where  there  was  excessive  hyperassthesia 
of  the  prolapsed,  thickened,  and  hypertrophied  bladder. 


444 


DISEASES   OF   WOMEN. 


consisting  of  removal  of  an  area  of  vaginal  mucous  mem- 
brane had  been  unavailabh'  performed.  There  I  found  the 
affection  dependent  on  long-standing  anteflexion  of  the 
uterus.  The  case  was  finally  and  completeh' cured  by  very 
considerably  narrowing  the  vaginal  aperture,  but  means 
were  at  the  same  time  taken  to  prevent  the  descent  of  the 
fundus  uteri  anteriorly,  which  had  evidently  been  the 
original  cause  of  the  mischief. 


Fig.  132. 


Rectocele,  and  its  relations  to  prolapsus,  constitutes  an 
important  subject.  Rectocele,  which  is  a  simple  projection 
of  a  loop  of  the  rectum  through  a  defective  vaginal  outlet, 
generally  arises  from  laceration  of  the  perineum.  It  by  no 
means  always  occurs  in  cases  of  lacerated  perineum,  and  it 
is  in  fact  rather  rare  by  itself.  It  varies  in  degree,  and  I 
have  generally  seen  it  associated  with  retroflexion  of  the 

*  Fig.  132  represents  the  condition  described  in  the  text,  the  subject 
of  which  was  a  ladv,  a?t.  42,  who  had  been  suffering  some  years  ;  ihe 
uterus  was  affected  wiih  chronic  retroflexion.  The  rectum  is  represented 
in  the  condition  it  always  assumed  in  the  act  of  straining. 


PROLAPSUS   OF   THE   UTERUS. 


445 


uterus,  though  it  is  not  by  any  means  the  fact  that  cases  of 
retroflexion  are  generally  complicated  with  rectocele.  In 
some  instances  the  affection  is  one  of  the  most  painful 
character  possible;  the  straining  at  stool  required  to  evacu- 
ate the  rectum  is  sometimes  severe,  and,  when  long  con- 
tinued, I  have  found  it  associated  with  an  ulcer  of  the  rec- 
tum, bleeding  on  the  slightest  irritation,  and  painful  when 

Fig.  133.* 


touched  to  an  extreme  degree.  The  nature  of  these  par- 
ticular cases  is  liable  to  be  misunderstood,  but  the  explana- 
tion seems  obvious  enough.  It  is  that  the  bend  in  the 
lower  part  of  the  rectum  prevents  the  passage  of  the  faeces, 

*  Fig.  133  represents  a  case  of  supra-vaginal  hypertrophy  of  the  cer- 
vi.x,  the  subject  of  which  was  a  married  woman,  xt.  47.  She  had  suf- 
fered from  prolapsus  for  two  years,  and  had  been  obliged  to  wear  a  box- 
wood pessary  3  J  inches  in  diameter  to  keep  the  uterus  up.  Iq  Huguier's 
memoir  similar  cases  will  be  found  delineated. 


44^ 


DISEASES    OF   WOMEN. 


which  are  impelled,  day  after  day  and  month  after  month, 
with  great  effort,  against  that  part  of  the  rectum  where  the 
bend  is,  the  result  being  to  produce  the  ulceration,  the 
bleeding,  and  other  grave  symptoms,  sometimes  to  such  a 
degree  as  to  compel  patients  the  subjects  of  them  to  declare 
that  life  is  not  worth  having  at  such  a  price.  In  some 
cases,  on  the  contrary,  the  inconvenience  sustained  from 
rectocele  is  less  marked. 

Fig.  134. 


Hypertrophy  of  the  uterus,  and  its  connection  with  pro- 
lapsus, is  a  subject  requiring  a  discussion  by  itself.  Hu- 
guier,*  in  1859,  described  and  figured  several  cases  desig- 
nated as  cases  of  hypertrophic  elongation  of  the  cervix 
uteri ;  and  his  researches  have  since  led  to  a  more  accurate 
discrimination  of  the  varying  conditions  met  with  in  pro- 
lapsus. 

Following  his  classification,  we  have  cases  of  (i)  Hyper- 
trophic elongation  of    the    part   of    the   cervix   above    the 


"Mem.  de  rAcadCm.  Imp.  dc  McJ.,"  torn.  x.\iii. 


PROLAPSUS   OF   THE    UTERUS. 


447 


vaginal  reflexion  (see  Fig.  133).  (2)  Cases  of  hj-pertrophic 
elongation  of  the  infra-vaginal  portion  of  the  cervix.  In 
both  these  cases  the  prolapsus  which  may  occur  is  consid- 
erable ;  but  in  the  first  case  the  bladder  is  of  necessity  pro- 
lapsed together  with  the  tumor,  while  in  the  second  (see 
Fig.  134)  the  bladder  is  not  necessarily  disturbed. 

in  both  classes  of  cases  the  fundus  uteri  may  remain  in 

Fig.  135. 


its  proper  position  in  the  pelvis,  and  it  is  obvious  that,  if 
there  be  still  a  considerable  prolapsus,  the  uterine  canal 
must  be  enormously  elongated.  So  in  point  of  fact  it  is, 
and  the  distance,  as  measured  by  the  sound,  may  be  found 
to  be  as  much  as  four  inches  from  the  os  to  the  fundus 
uteri  ;  in  extreme  cases  more  than  this. 

The  cases  of  supra-vagmal  hypertrophy  are  met  with 
chiefly  in  laundresses  and  cooks,  whose  occupations  involve 
long  standing.  The  mechanism  of  the  occurrence  of  this 
peculiar  elongation  of   the   cervix   is   curious.     It   wouU 


448 


DISEASES  CF  \70MEN. 


appear  that  the  elongation  is  due  to  the  dragging  of  the 
vaginal  portion  on  the  supra-vaginal  portion  of  the  cervix, 
in  consequence  of  which  the  organ  becomes  stretched. 
The  bladder  very  probably  descends  first  in  these  cases, 
either  because  the  perineum  is  a  little  deficient,  or  because 
the  fundus  is  inclined  forward,  and  the  effect  of  the  descent 
of  the  bladder  is  that  the  cervix,  which  is  intimately  ad- 


FlG. 


herent  to  the  bladder,  descends  with  it,  the  result  being 
elongation  of  the  cervix.  This  mechanism  implies  a  fixa- 
tion of  the  upper  part  of  the  uterus.  In  some  cases  the 
weight  of  the  vaginal  part  of  the  cervix  alone  appears 
enough  to  determine  this  hypertrophic  elongation,  when 
the  patient  has  been  subjected  to  the  influences  of  pro- 
longed standing  exertion. 

We  meet  with  all  gradations  of  the  affection.  The  ac- 
companying figures  represent  actual  cases.  In  Fig.  134 
Vv'e  have  simple  hypertrophic  elongation  of  the  infra-vaginal 


t>ROLAPSUS    OF  THE   UTERUS.  449 

portion  in  a  young  woman.  In  Fig.  135  is  shown  elonga- 
tion of  the  infra-vaginal  portion  from  a  woman  who  had 
had  children.  In  Fig.  136  we  have  hypertrophic  elonga- 
tion of  the  same  portion  in  association  with  retroflexion,  a 
rare  combination. 

I  have  seen  cases  in  which  the  external  tumor  consti- 
tuted by  the  prolapsed  organs  has  been  as  large  as  the 
foetal  head.  Under  these  circumstances  there  is  great 
thickening  of  the  cellular  tissue  around  the  uterus.  The 
organ  itself  is  greatly  thickened  and  hypertrophied  laterally 
as  well  as  longitudinally,  and  in  some  cases,  togetiier  with 
the  bladder  and  uterus,  certain  coils  of  the  intestine  pass 
downward  and  help  to  enlarge  the  tumor. 

Huguier's  statements  as  to  the  frequency  of  hypertrophic 
elongation  of  the  cervix  are  not  borne  out  by  my  own  ex- 
perience. In  other  respects,  as  regards  the  collateral  con- 
tlitions  in  these  particular  cases  Huguier's  account  has 
seemed  to  be  exact. 

The  foregoing  represent,  regarding  prolapsus  generally, 
the  generalizations  I  have  been  led  to  adopt.  The  very 
great  importance  of  flexions,  as  in  many  instances  the 
starting-point  of  the  displacement,  is  a  matter  which  it 
seems  desirable  to  make  prominent. 

Various  secondary  effects  result  from  prolapsus.  Thus, 
in  cases  of  cystocele  the  bladder  is  evacuated  with  diffi- 
culty, retention  of  a  small  portion  of  urine  is  apt  to  occur, 
and  chronic  cystitis  may  be  added  as  a  complication.  The 
uterus  itself,  when  prolapsed,  often  becomes  ulcerated  and 
excoriated,  broad  patches,  the  size  of  the  palm  of  the  hand, 
raw  and  bleeding  on  the  slightest  touch,  are  observed 
round  the  os  uteri,  these  ulcerations  being  produced  by  the 
friction  of  the  tumor  against  the  thighs.  The  tumor  itself, 
from  long  exposure,  becomes  sometimes  hard  and  leathery 
to  the  touch,  the  inverted  vaginal  mucous  membrane  losing 
the  characters  of  mucous  membrane  and  looking  more  like 
the  adjacent  skin.  The  discomforts  connected  with  de- 
fsecation  are  great,  and,  as  already  stated,  in  the  case  of 
rectocele  they  may  themselves  become  actually  torturing. 
Needless  to  say,  the  general  discomfort  induced  by  the 
presence  of  a  tumor  at  the  vulva,  changing  in  size  from 
time  to  time,  impeding  locomotion,  distressing  the  patient 
by  giving  rise  to  profuse  leucorrhoea,  occasional  losses  of 
blood,  and  in  many  other  ways — all  these  constitute  grave 
ailments. 


456  DISEASES   OF   WOMEN. 

Lastly,  in  some  cases,  the  tumor  may  be  so  large  and  so 
much  swollen  that  it  becomes  actually  strangulated  and 
mortification  sets  in;  again,  inflammatory  adhesions  may 
occur  to  such  a  degree  round  the  pedicle  of  the  tumor  that 
its  return  is  found  difficult,  and  in  a  few  cases  impossible. 

DIAGNOSIS. 

All  cases  of  prolapsus  uteri  have  this  in  common,  that 
the  OS  uteri  is  the  lowest  point.  In  other  respects,  the 
variations  observed  are  exceedingly  great.  In  the  most 
simple  form  of  the  affection  the  cervix  uteri  is  felt  rather 
lower  than  usual,  and  the  vagina  proportionately  shortened. 
In  its  extreme  degree,  on  the  other  hand,  the  uterus  de- 
scends so  low  down  as  to  be  almost  altogether  outside  the 
ostium  vaginae;  and  in  this  case  the  vaginal  canal  is  com- 
pletely inverted,  the  bladder  is  dragged  externally  also,  and 
the  rectum  may  be  displaced  in  like  manner.  Thus,  in  a 
bad  case  of  prolapsus  uteri  we  may  have  combined,  de- 
scent of  the  uterus  with  prolapsus  of  the  bladderand  rectum 
(vaginal  cystocele  and  rectocele). 

If  we  find  a  conical,  firm  tumor,  smooth  on  the  surface, 
projecting  downward  in  the  vagina  or  beyond  it,  and  the 
OS  uteri  situated  at,  or  close  to,  its  extremity,  the  case  is 
one  of  hypertrophy  and  elongation  of  the  vaginal  portion  of  the 
cervix  uteri.  With  such  a  condition  there  is  usually  found 
no  considerable  amount  of  prolapsus  of  the  vagina,  and  the 
finger  encounters  the  cul  de  sac  of  the  vagina  in  about  its 
usual  position  (see  Figs.  134  and  135).  The  shape  of  the 
tumor  is  generally  conical,  but  it  may  be  larger  at  the  ex- 
tremity than  at  the  base;  one  portion  of  the  lip  may  be 
larger  than  another,  in  which  case  the  opening  appears  to 
be  not  quite  at  the  extremit)'  of  the  growth,  and  the  os  it- 
self ma}'  be  fissured  and  ulcerated  according  to  the  degree 
of  irritation  to  which  the  part  is  exposed.  The  general 
shape,  the  firmness  of  the  tumor,  and  the  position  of  the  os 
uteri,  sufficiently  distinguish  it  from  other  tumors  occupy- 
ing the  vagina. 

Hypertrophy  of  the  Supra-vaginal  Part  of  the  Cervix. — In 
this  class  of  cases  there  is  prolapsus  of  the  vagina,  and  the 
finger  cannot  consequently  be  introduced  as  far  as  usual. 
The  use  of  the  sound  will  render  it  evident  at  once  whether 
the  descent  of  the  os  uteri,  bringing  with  it  the  vagina,  is 
due  to   descent  of   the  whole  uterus,  or  to   hypertrophy  of 


PROLAPSUS   OF  THE   UTERUS. 


451 


the  lower  part  of  this  organ — the  cervix.  The  attachment 
of  the  cervical  part  of  the  uterus  to  the  bladder  in  front  is 
such,  that  when  the  cervix  is  projected  downward  the  blad- 
der comes  with  it;  the  extent  of  the  prolapsus  of  the  blad- 
der is,  as  a  rule,  dependent  on  the  degree  of  the  former. 
l''g-  137  (fi'om  Dr.  Farre)  represents  such  a  condition. 
(See  also  Fig.  133.)  In  like  manner,  the  rectum  is  liable, 
but  in  a  less  degree,  to  be  prolapsed  with  the  lower  part  of 


Fir,.   137. 


the  uterus;  and  the  result  is  that  in  cases  of  extensive  pro- 
lapsus of  the  cervix,  whether  with  or  without  hj'pertrophy 
of  the  part,  tliere  is  a  soft  tumor  in  front — the  bladder — 
and  a  smaller  one  behind — the  rectum — between  which  two 
the  OS  uteri  is  situated.  A  combined  examination  of  the 
rectum  by  the  finger  and  of  the  bladder  by  means  of  the 
sound,  will  determine  whether  or  not  the  fundus  uteri  is  in 
its  proper  position;  the  use  of  the  uterine  sound  gives  in- 
formation of  a  like  character. 

True  prolapsus  of  the  ivhole  uterus  may  be  found  associated 
with  ascites,  ovarian  tumors,  or  both,  or  with  relaxation  of 
the  vaginal  structures,  consequent  on  frequent  child-bear- 
ing. 


452  DISEASES   OF  WOMEN. 

Prolapsus,  complete  or  produced  by  hypertrophy  of  the 
supra-vaginal  portion  of  the  cervix,  could  hardly  be  mis- 
taken for  polypus,  inversion  of  the  uterus,  or  large  tumors 
growing  from  the  os  uteri,  if  attention  were  paid  to  the 
position  of  the  os  in  reference  to  the  body  of  the  tumor. 
Cases  of  hypertrophy  of  the  vaginal  portion  alone  might 
possibly  be  confounded  with  a  polypus  projecting  into  the 
vagina  from  the  interior  of  the  uterus,  in  those  instances  in 
which  the  os  uteri  is  distorted,  partially  effaced,  or  so 
altered  as  not  to  be  recognized  as  such  by  a  casual  observer. 
I  have  known  an  instance  in  which  a  lady  was  treated  for 
prolapsus  and  made  to  wear  a  pessary  for  several  months, 
the  tumor  being  a  well-marked  specimen  of  polypus,  at- 
tached b)'  a  slender  pedicle  to  the  interior  of  the  cervix 
uteri. 

Prolapsus  combined  7c<ith  Pregnancy. — In  some  rare  cases 
the  uterus,  although  prolapsed,  becomes  impregnated.  It 
would  be  a  serious  mistake  to  use  the  sound  in  such  a  case, 
and  to  induce  abortion.  It  is  sufficient  here  to  give  this 
caution  on  the  subject. 


TREATMENT    OF    THE    VARIOUS    FORMS   OF    PROLAPSUS. 

The  various  forms  of  prolapsus  of  the  uterus,  vagina, 
etc.,  having  a  different  mechanism  in  different  cases,  the 
treatment  necessarily  varies.  Success  in  treatment  cannot 
be  obtained  until  due  importance  is  attached  to  the  various 
elements  concerned  in  the  production  of  the  prolapsus. 

We  may  consider,  in  the  first  place,  the  treatment  of 
those  cases  in  which  there  is  hypertrophy  of  the  cervix — the 
prolapsus  being  for  the  most  part  due  to,  or  constituted 
by,  this  hypertrophy. 

(a)  Cases  of  Hypertrophy  of  the  Vagifial  Portion  alone. — It 
appears  that  in  many  of  these  cases  the  hypertrophy  of  the 
cervix  may  be  very  greatly  diminished  by  appropriate 
treatment — viz.,  by  rest,  by  frequent  hot  douches,  and  by 
the  use  of  astringent  applications.  Further,  that  in  a  cer- 
tain number  of  these  cases  the  hypertrophy  at  the  os  uteri 
is  due  to  laceration  of  the  cervix  and  consequent  hj'per- 
trophy  and  eversion.-  Cases  of  the  latter  description  should 
of  course  be  dealt  with  by  the  operation  described  in  a 
former  chapter. 

The  great  length    of  the  cervix  sometimes  appears  to 


PROLAPSUS   OF  THE   UTERUS.  453 

be  capable  of  undergoing  great  reduction  by  appropriate 
measures,  particularly  rest  and  absence  of  traction  on  the 
cervix.  Still  cases  remain  in  which  after  proper  treatment 
has  been  employed  the  only  real  cure  consists  in  amputation 
of  the  enlarged  cervix.  The  removal  may  be  effected  by 
the  knife  or  curved  scissors,  by  the  wire  or  chain  ecraseur, 
by  the  galvano-caustic  apparatus,  or  by  Paquelin's  thermo- 
cautery. The  knife  is  the  more  expeditious  and  manage- 
able; but  the  haemorrhage  from  the  cut  surface  is  often 
very  troublesome.  An  objection  to  the  ecraseur  is  that, 
unless  the  chain  fits  closely  into  the  apex  of  the  instrument, 
there  is  a  liability  of  drawing  into  the  instrument  tissues 
which  ought  to  be  left  uninjured.  Hence,  if  the  chain 
ecraseur  be  used,  the  chain  should  be  applied,  not  close  to 
the  summit  of  the  vagina,  but  a  little  below  this.  Dr. 
Thomas  describes  in  his  last  edition  a  pair  of  forceps  with 
long  teeth,  b}'  means  of  which  the  cervix  is  seized  prior  to 
the  amputation,  and  the  slipping  upward  during  severance 
by  the  wire  thus  prevented.  The  galvano-caustic  apparatus 
has,  like  the  ecraseur,  the  advantage  of  preventing  haemor- 
rhage. On  the  whole,  the  course  to  be  recommended  is  the 
use  of  the  knife,  or  curved  scissors,  if  the  neck  of  the  growth 
be  very  thick — the  cautery  being  ready  for  use  to  arrest 
haemorrhage,  and  the  use  of  the  chain  or  wire-rope  ecraseur 
(see  Fig.  138),  or  the  thermo-cautery  when  the  neck  of  the 
tumor  is  smaller.  Lint  soaked  in  tincture  of  sesquichloride 
of  iron  on  the  cut  surface,  and  carefully  plugging  the  vagina 
by  means  of  the  speculum,  as  in  ordinary  cases  of  uterine 
haemorrhage,  will  be  effectual  in  arresting  the  bleeding  in 
many  cases.  In  any  case,  prior  to  performing  the  opera- 
tion, the  tumor  should  be  gently  pulled  down  as  far  as 
possible,  to  facilitate  the  necessary  manipulations.  It  is  a 
wise  precaution  to  transfix  the  cervix  above  the  line  of  the 
contemplated  incision,  and  to  pass  a  stout  piece  of  string 
through  it  before  performing  the  excision,  for  it  often  hap- 
pens that  the  uterus  retracts,  and  bleeding  is  thereby  less 
under  control. 

Dr.  Marion  Sims  has  practiced  a  modification  of  this  op- 
eration. This  consists  in  covering  the  stump,  as  it  may  be 
termed,  of  the  amputated  part,  by  mucous  membrane;  the 
anterior  half  being  covered  with  mucous  membrane  pre- 
viously dissected  off,  and  being  made  to  lap  over,  as  in  the 
flap  operation   in  ordinary  amputation;  and   the  posterior 


454  DISEASES   OF   WOMEN. 

half  being  covered  by  a  flap  similarly  made  from  the  under 
surface  of  the  cervix.  When  the  bleeding  is  trifling  and 
readily  checked,  this  procedure  renders  the  operation  more 
neat  and  perfect.  If  styptics  have  to  be  used,  the  covering 
of  the  stump  with  mucous  membrane  will  be  useless,  as  no 
union  can  occur. 

{/>)  Cases  of  Hypertrophy  of  the  Supra-vaginal  Portion  of 
the  Cervix  Uteri. — Cases  of  hypertrophic  elongation  of  the 
cervix  are  now  not  uncommonly  treated  after  the  manner 
proposed  by  Huguier — viz.,  by  excision;  and  this  plan  I  have 
satisfactorily  carried  out  in  some  few  instances. 

When  the  hypertrophy  is  very  great  this  is  the  onl)''  sat- 
isfactory treatment;  but  before  deciding  on  its  necessity, 
the  patient  should  be  kept  in  bed  for  a  week  or  two,  in 
order  that  it  may  be  ascertained  how  far  tlie  affection  is  re- 
duced by  this  rest.  It  is  the  fact,  as  pointed  out  by  Kiwisch, 
that  rest  materiall}'  reduces  the  bulk  of  the  cervix  under 
these  circumstances.  Rest  and  prolonged  use  of  cold  ef- 
fusions would  do  still  more.  But  when  the  disease  is  of 
long  standing,  and  the  uterine  canal  exceeding  a  total  lengtli 
of  four  inciies,  such  palliative  measures  are  inadequate. 
And  the  poorer  classes,  amongst  whom  the  disorder  is  most 
marked,  can  ill  afford  the  prolonged  rest  and  attention 
requisite.  Two  plans  of  a  palliative  nature  are  open  to  us 
— (i)  The  use  of  pessaries,  and  (2)  the  closure  of  the  vagi- 
nal orifice  to  such  an  extent  as  to  prevent  the  escape  of  the 
cervix  uteri,  after  a  plan  to  be  presently  described.  Each 
of  these  methods  of  treatment  has  peculiar  advantages, 
according  to  the  nature  of  the  case.  In  many  instances 
the}'  prove  sufficient;  but  in  some  few  cases,  as  might  be 
surmised,  they  are  either  inapplicable,  or,  in  the  long  run, 
unsatisfactory. 

The  operation  of  Huguier  is  accomplished  as  follows:  An 
incision  is  made  behind  the  os  uteri  through  the  vaginal 
wall,  of  a  semicircular  form,  and  directed  toward  the  cen- 
tre of  the  cervix.  Dissection  is  now  made  upward,  in  order 
to  expose  the  hypertrophied  cervix,  and  separate  it  from  its 
connections  posteriorly — great  care  being  necessarj'  to  avoid 
the  reflection  of  peritoneum  there  situated.  A  correspond- 
ing incision  and  dissection  is  made  now  in  front;  here,  how- 
ever, great  care  is  necessary  to  avoid  injuring  the  bladder. 
As  much  of  the  cervix  having  been  exposed  as  is  considered 
advisable,  it  is  removed  by  the  knife.     Huguier  at  first  em- 


PROLAPSUS  OF  THE   UTERUS. 


ployed  the  knife  in  removing  the  cervix,  but  subsequently 
the  ecraseur,  finding  the  haemorrhage  trou- 
blesome when  the  knife  is  used.     Such  is  an        ^^*^-  ^38. 
outline  of  the  operation   in  question.     The 
result  is  that  a  conical  piece  of  tissue  is  re- 
moved, including  the  os  uteri,  the  vaginal, 
and  a  portion  of  the  supra-vaginal  part  of     N    \ 
the  cervix.     In  the  original  memoir  before 
referred  to,  Huguier  states  that  he  had  per- 
formed the  operation  in  fourteen  cases.     In 
only  one  of  such  cases  a  fatal  result — not 
due,  however,  to  the  operation — followed. 

The  operation  is,  judging  from  my  own  ex- 
perience, a  sound  one,  and  in  some  instances 
offers  the  shortest  road  to  the  cure  of  the 
patient.  The  dissection  and  exposure  of  the 
cervix  is  the  part  attended  with  most  diffi- 
culty, and  it  must  be  done  with  care.  The 
bladder  may  extend  to  within  half  an  inch 
of  the  OS  uteri,  in  which  case  it  is  evident 
that  great  caution  must  be  required  to  avoid 
wounding  it;  again,  the  peritoneal  reflection 
behind  must  be  sedulously  preserved  intact. 
By  keeping  close  to  the  cervical  hard  tissue 
these  objects  are  secured.  A  sound  in  the 
bladder  shows  the  position  of  that  viscus, 
and  acts  as  a  good  guide  during  the  opera- 
tion. For  the  dissection  itself  scissors 
should  be  used;  the  knife  occasions  trouble- 
some bleeding.  I  believe  that  a  deep  dis- 
section— beyond  an  inch  and  a  half,  or  at 
most  two  inches — is  rarely  required;  for  if 
the  hypertrophied  and,  usually,  thickened 
cervix  be  excised  to  this  extent,  the  rest, 
which  necessarily  follows  the  operation,  will  suffice  to  com- 
plete the  cure.  Retraction  of  the  severed  cervix  must  be 
guarded  against  by  previously  transfixing  the  uterus  above 
that  point.  The  edges  of  the  mucous  membrane  maj' be 
brought  over  the  stump,  and  the  opposite  side  secured  by 
sutures  so  as  to  cover  it,  after  Dr.  Sims's  plan,  if  it  be  pre- 
ferred. 

Of  the  various  forms  of  the  ecraseur,  the  steel  wire-rope 

*  Ecraseur  to  be  used  with  annealed  steel  wire.     (Meyer  &  Meltzer.) 


456  DISEASES  OF  WOMEN. 

ecraseur  is  more  useful  in  amputating  the  cervix  in  such 
cases,  in  Messrs.  Meyer  &  Meltzer's  instrument  (see  Fig. 
138)  the  wire  and  the  slit  fit  accurately,  and  there  is  less 
liability  to  draw  in  extraneous  tissues,  while  the  power  of 
the  instrument  is  exceedingly  great. 

Prolapsus  without  Elongatio7i  of  the  Cervix. — These  include 
the  more  ordinary  cases  of  prolapsus.  In  dealing  with  this 
class  of  cases,  the  indications  are  almost  always  various; 
the  treatment  must  have  regard  both  to  the  primary  cause 
and  the  secondary  effects,  (i)  The  condition  of  the  uterus 
itself,  and  (2)  the  condition  of  its  supports,  have  to  be  con- 
sidered, and  appropriate  measures  devised  for  rectifying 
defects  and  disorders. 

1.  The  Condition  of  the  Uterus. — In  most  cases  of  prolap- 
sus the  starting-point  has  been  a  defective  or  altered  con- 
dition of  the  uterus,  which  would  have  proved  perfectly 
and  completely  amenable  to  treatment.  Apart  from  those 
special  cases  of  hypertrophic  elongation  of  the  cervix  which 
have  been  alread}'  dealt  with,  the  condition  of  the  uterus 
which  most  frequently  calls  for  therapeutic  measures  in 
cases  of  prolapsus,  is  undue  size  and  fulness  of  the  organ, 
very  frequently  indeed  associated  with  long-standing  flex- 
ion and  other  troublesome  alteration  in  its  shape.  The 
treatment  required  in  cases  where  there  is  flexion,  so  far  at 
least  as  the  uterus  itself  is  concerned,  has  been  discussed 
under  the  head  of  Flexions,  and  it  need  not  be  here  re- 
peated. It  must  not  be  forgotten,  however,  that  cases  of 
prolapsus,  really  due  primarily  to  flexion,  cease  to  present 
that  element  in  a  recognizable  form  when  the  affection  has 
lasted  many  years.  All  we  see  then  is  the  extremely  ad- 
vanced prolapsus;  the  uterus  itself  is  by  that  time  other- 
wise changed. 

Among  the  general  measures  always  required  in  these 
cases,  rest,  verj'  careful  attention  to  the  bowels  so  as  to 
avoid  necessity  for  straining,  injections,  and  a  careful 
dietary,  are  very  important. 

2.  The  Condition  of  the  Uterine  Supports. — The  methods  of 
treatment  which  have  formerly  been  had  recourse  to  for 
preventing  or  curing  prolapsus  were  based  on  the  one  idea 
of  keeping  the  tumor  from  escaping  at  the  vaginal  aperture. 
Bandages,  external  pads,  boxwood  or  disk-shaped  pessaries 
applied  internally,  were  the  principal  measures  of  "sup- 
porting" the  uterus  and  supplying  defects  of  the  natural 
supports.     Next  came  improvements  in  the  shape  of  opera- 


PROLAPSUS  OF  THE  UTERUS.         45/ 

tions  for  constricting  the  canal  of  the  vagina,  and  thus  re- 
storing the  lost  support  in  a  more  natural  manner.  But 
there  is  yet  room  for  improvement,  and  that  improvement 
is  only  to  be  attained  by  a  careful  attention  to  the  restora- 
tion not  simply  of  the  outlet  of  the  vagina,  but  the  position 
of  the  uterus  in  the  pelvis.  In  other  words,  it  is  not  suffi- 
cient to  simply  shut  up  the  uterus  in  the  vagina  by  means 
of  a  perineal  operation,  for  most  assuredly,  if  the  uterus 
be  in  a  chronic  flexed  state,  it  will  continue  to  excite  ex- 
pulsive efforts,  and  the  restored  perineum  will  by  and 
by  give  way.  Even  in  single  women  who  have  never  had 
children,  and  when  the  perineum  has  never  been  dilated 
or  destroyed  by  a  foetal  head,  very  extreme  degrees  of  pro- 
lapsus are  sometimes  witnessed. 

Supposing  the  uterus  to  have  been  reduced  by  treatment 
to  its  proper  size  and  shape,  we  have  next  to  consider  hoiu 
to  maintain  it  in  its  proper  place  in  the  pelvis.  It  must  be  quite 
obvious  that  unless  this  indication  is  complied  with,  the 
evil  is  likely  to  recur.  It  is  in  this  direction  that  improve- 
ments in  the  treatment  of  prolapsus  must  be  made.  The 
cervical  part  of  the  uterus  should  occupy  a  position  in  the 
pelvis  which  is  as  nearly  as  possible  its  centre.  The  mechan- 
ism applied  and  the  operations  devised  must  have  regard 
to  this  important  circumstance. 

Instead,  therefore,  of  endeavoring  simply  to  keep  the 
uterus  within  the  vagina,  attempts  should  be  made  to  main- 
tain it  in  position  at  the  top  of  this  canal,  which  is  its 
proper  place.  Admitting  that  this  perfection  of  treatment 
is  not  possible  in  all  cases,  it  is  nevertheless  practicable  in 
most  instances. 

The  principle  of  treatment  which  fulfils  this  indication 
is  to  render  tlie  vaginal  canal  rigid,  thereby  giving  support 
to  the  lower  part  of  the  uterus,  and  to  adopt  such  otlier 
measures  as  may  maintain  the  vaginal  canal  in  this  rigid 
condition.  In  many  cases  this  rigidity  of  the  canal  can  be 
supplied  by  means  of  a  pessary  which,  adapted  to  the  re- 
quirements of  the  patient,  becomes  practically  an  artificial 
vaginal  stem  to  the  uterus;  and  in  certain  other  cases,  where 
the  vaginal  aperture  has  become  too  large  to  retain  such  an 
instrument,  it  must  be  constricted  by  operation. 

Apply  these  principles  to  the  consideration  of  actual 
cases.  Cases  of  slight  cystocele  associated  with  anteflexion 
may  be  generally  cured  by  the  wearing  of  a  well-adjusted 
"cradle"  pessary  as  described   in   the  treatment  of  ante- 


458  DISEASES   OF   WOMEN. 

flexion;  but  if  the  cystocele  be  of  long  standing,  a  constric- 
tion of  the  vaginal  aperture  by  operation  is  necessary,  the 
instrument  being  worn  subsequently.  An  air-ball  pessary 
is  a  palliative  measure  in  some  of  these  cases,  where  the 
cradle  is  inconvenient,  or  difficult  to  adjust,  and  where  the 
perineal  aperture  is  not  much  increased  in  size.  In  the 
case  delineated  in  Fig.  131  no  treatment  short  of  a  consider- 
able narrowing  of  the  vaginal  aperture  was  sufficient,  the 
prolapsed  portion  of  bladder  being  hypertrophied  and  much 
thickened. 

In  cases  where  the  prolapsus  is  dependent  simply  on  ret- 
roflexion of  the  uterus  without  much  laceration  of  the 
perineum,  the  Hodge  pessary  is  a  most  admirable  instru- 
ment when  properly  adjusted.  It  carries  out  the  indica- 
tions above  alluded  to,  maintaining  the  vagina  in  its  proper 
position,  and,  at  the  same  time,  and  often  quite  efficiently, 
preventing  the  uterus  from  resuming  its  retroflexed  posi- 
tion. Within  certain  limits  it  acts  very  well,  but  attention 
must  be  paid  to  the  following  points.  As  stated  in  the 
chapters  on  Flexions,  if  the  flexion  be  of  long  standing  the 
pessary  alone  may  fail  to  cure  it,  other  measures  being  re- 
quisite; but,  once  cured,  the  pessary  will  prevent  its  recur- 
rence, and,  moreover,  it  will,  if  there  be  sufficient  perineal 
support  below,  prevent  prolapsus  occurring.  The  instru- 
ment must  be  adapted  to  the  size  of  the  vagina.  A  pessary 
made  from  a  ring  three  inches  or  three  and  a  quarter  inches 
in  diameter,  having  the  shape  shown  at  page  266,  generally 
answers  the  purpose  in  such  cases  as  those  contemplated; 
it  must  sometimes  be  made  broader  below  than  above. 
The  copper-wire  india-rubber  covered  rings  which  I  em- 
ploy lend  themselves  admirably  to  the  necessary  process  of 
fitting,  for  nothing  can  be  a  greater  mistake  than  to  sup- 
pose that  one  instrument  will  fit  all  cases.  The  instrument 
must  be  adjusted  to  the  case,  and,  when  properly  fitted, 
may  be  worn  for  months  without  inconvenience.  In  some 
cases  the  watch-spring  india-rubber  covered  round  pessary 
answers  very  well;  but  only  when  the  perineum  has  been 
properly  repaired. 

If  there  be  rectocele,  whether  associated  with  retroflexion 
or  not,  the  case  generally  requires  an  operation  to  restore 
the  injured  perineum.  Subsequently,  the  uterus  often  re- 
quires to  be  sustained  in  its  position  by  a  pessary,  as  above 
directed  for  retroflexion.  The  rectocele  may  be  slight  in 
degree,  the  tumor  small,  but  instruments  are   useless   in 


PROLAPSUS   OF   THE    UTERUS.  459 

such  cases,  because  the  prolapsed  bowel  is  so  near  the 
vaginal  aperture.  The  discomfort  attending  these  cases  of 
rectocele  is  sometimes  relieved  by  giving  very  small  (tea- 
spoonful)  doses  of  castor-oil  every  morning. 

We  next  come  to  those  cases  where  the  mass  protruded 
is  large,  and  where  the  vaginal  aperture  is  very  large,  be- 
cause it  has  been  very  much  torn  in  labor.  When  the 
whole  mass  prolapsed  does  not  exceed  the  size  of  a  hen's 
egg,  we  may  hope,  under  favorable  circumstances,  to  satis- 
factorily treat  the  case,  without  an  operation,  by  the  use  of 
instruments.  Sometimes  we  are  foiled  even  then,  for  what 
appears  to  be  a  tolerably  good  perineum  may  not  give  suf- 
ficient basis  for  maintaining  a  suitable  pessary  in  its  place. 
When  the  mass  exceeds  in  bulk  the  size  of  an  egg,  a  real 
cure  is  rarely  obtained  without  an  operation. 

First  of  all  we  may  speak  of  palliative  measures,  for  even 
in  the  worst  cases  some  patients  reject  operative  measures, 
and  in  some  the  age  of  the  patient  or  other  circumstances 
put  an  operation  on  one  side. 

The  mere  reJuctioii  of  the  tumor  is  sometimes  ver}'  difficult, 
when  the  parts  have  been  some  weeks  prolapsed,  and  the 
neck  thickened  by  inflammation.  To  eff<  ct  reduction  the 
urine  should  be  removed  by  catheter,  the  patient  placed  in 
a  favorable  position,  and  the  pedicle  or  neck  of  the  tumor 
well  covered  with  oil.  Seizing  the  tumor  between  the  two 
hands  it  is  then  gently  compressed  from  side  to  side,  and 
pressed  upward,  the  attempt  being  made  in  such  manner 
that  the  part  last  prolapsed  shall  be  first  reduced.  Attempts 
made  otherwise  and  by  simply  pushing  the  mass  in  an  up- 
ward direction  may  altogether  fail,  but  the  plan  above 
directed  I  have  always  found  successful.  Dr.  McClintock 
suggested  strapping  the  tumor  in  order  to  reduce  its  bulk. 
I  have  never  found  this  necessary.  The  ulcerations  or 
abrasions  of  surface  seen  in  such  cases  readily  heal  when 
the  tumor  is  reduced. 

There  are  no  doubt  many  cases  in  which  the  uterus  is 
much  hypertrophied  and  has  become  prolapsed  with  or 
without  considerable  increase  in  the  size  of  the  cervix,  and 
which  at  first  sight  may  seem  difficult  to  treat  without  some 
operative  procedure,  but  it  will  be  found  that  by  a  continu- 
ous system  of  rest,  irrigations  of  the  uterus,  use  of  astrin- 
gents, etc.,  the  bulk  of  the  organ  becomes  greatly  reduced, 
and  the  case  loses  its  formidable  characters.  Dr.  Emmet 
in  the  last  edition  of  his  valuable  work  tells  an  amusing 


460  DISEASES   OF   AYOMEN. 

Story,  illustrative  of  this  part  of  the  subject.  An  eccentric 
but  shrewd  physician  of  the  Currituck  district,  after  having 
been  shown  Dr.  Emmet's  cases  and  practice  in  cases  of  pro- 
lapsus, told  him  he  could  cure  any  case  in  ten  days.  His 
practice  was  among  the  negroes.  "His  plan  was  to  swing 
the  woman  in  a  sling  from  a  beam,  in  the  knee-and-chest 
position.  This  was  maintained  for  ten  days,  during  which 
time  the  vagina  was  kept  filled  with  a  strong  decoction  of 
oak  bark,  which  was  changed  every  day  by  means  of  a 
syringe.  The  sling  was  padded,  the  woman  slept  all  the 
time,  and  was  not  disturbed  except  to  receive  her  food  or 
answer  a  call  of  nature."  "  The  principles  of  the  treatment 
were,"  Dr.  Emmet  states,  "correct." 

Internal  Supports. — In  a  case  where  the  uterus  has  been  in 
a  state  of  retroflexion  a  pessary  must  be  adapted  suited  to 
the  case.  It  generally  happens  that  in  the  cases  coming 
properly  under  consideration  in  this  place  an  ovoid  ring 
answers  extremely  well,  but  the  Albert  Smith  type  of 
Hodge  pessary  is  necessary  in  many  instances.  The  quite 
round,  rather  thickly  covered  watch-spring  pessary  answers 
well  in  some  cases.  In  a  few  the  disk-shaped  ebonite  pes- 
sary is  found  suitable;  various  sizes  are  required.  In  some 
cases  I  have  found  a  rather  large  cradle  pessary  most  ser- 
viceable, particularly  in  cases  where  the  uterus  has  been 
previously  in  a  state  of  anteversion.  The  use  of  these  sup- 
ports is,  in  bad  cases,  not  generally  satisfactory,  unless  the 
perineum  has  been  effectually  restored  by  operation. 

Various  forms  of  air  pessaries,  globular  as  well  as  disk- 
shaped,  are  kept  by  the  instrument  makers,  but  they  are 
not  satisfactory  for  prolonged  treatment,  while  open  of 
course  to  objections  already  mentioned. 

Zwank's  pessary  has  been  in  rather  general  use.  It  is  an 
unscientific  instrument,  inasmuch  as  it  distends  the  vagina 
very  greatly  from  side  to  side,  and  perpetuates  the  prolap- 
sus by  dragging  the  uterus  still  lower  toward  the  vulva: 
the  only  merit  it  possesses  is,  that  it  prevents  the  escape  of 
the  mass  from  the  vulva. 

External  Supports. — Under  this  head  are  included  me- 
chanical contrivances  for  preventing  prolapsus,  having  their 
fixed  point  from  without.  The  perineal  pad  and  bandage 
consists  of  an  elastic,  or  non-elastic,  abdominal  belt,  whicli 
is  the  fixed  point,  and  a  perineal  pad,  which  is  of  a  flattened 
egg  shape,  and  is  so  adjusted  by  x  strap  fixed  anteriorly 
and  posteriorly  to  the  abdominal  bandage  as  to  press  upon 


PROLAPSUS  OF  THE  UTERUS.  461 

the  edge  of  the  perineum.  The  pad  is  sometimes  made 
elastic  by  means  of  an  india-rubber  air-ball.  This  appara- 
tus supplies  in  some  degree  the  deficiency  of  the  perineum, 
and  prevents  in  some  cases  of  prolapsus  the  expulsion  of 
the  mass  outside  the  vulva.  Here  of  course  its  function 
ceases.  In  some  cases  straps  passed  over  the  shoulders  are 
the  fixed  points,  being  used  instead  of,  or  as  an  assistance 
to,  the  abdominal  bandage. 

Another  principle  of  treatment  consists  in  the  use  of  a 
rigid  stem  of  metal  or  other  material,  which,  terminating 
above  in  the  form  of  a  small  ball,  or  cup-shaped,  is  main- 
tained in  the  vagina  by  means  of  a  perineal  strap,  attached 
to  an  abdominal  bandage.  External  frameworks  of  metal 
fixed  anteriorly  to  the  abdominal  bandage,  or  to  a  kind  of 
liernia  belt,  may  be  made  the  basis  of  support  to  such  intra- 
vaginal  stems.  It  is  obvious  that  from  without  it  is  possi- 
ble in  this  manner  to  adjust  an  internal  support  very  firmly. 
The  inconvenience  attached  to  the  wearing  of  such  external 
solid  mechanical  supports  is  a  great  objection  to  them,  but 
if  external  supports  are  to  be  made  really  eflicient,  some 
such  principle  of  construction  as  this  is  required.  Obvi- 
ously, the  alternative  is  the  performance  of  an  operation 
which  will  radically  cure. 

Radical  Operations. — The  success  with  which  the  very 
worst  forms  of  prolapsus  can  now  be  treated  by  operation 
will  render  this  method  more  and  more  popular,  especially 
if  after  such  operations  care  be  taken  to  deal  with  the 
uterus,  and  promote  its  restoration  to  shape  and  position 
in  the  pelvis.  The  principle  of  the  operation  is  to  constrict 
the  vaginal  canal.  Dr.  Marshall  Hall  seems  to  have  been  the 
first  lo  suggest  it,  and  Mr.  Heming  the  first  to  have  prac- 
ticed it.  The  part  of  the  vaginal  canal  so  dealt  with  was  at 
first  the  lower  apertuie  or  entrance  of  the  vagina,  and  this 
operation  received  later  on  important  developments  at  the 
hands  of  Mr.  Baker  Brown,  Dr.  Savage,  and  others.  A 
further  step  consists  in  the  constriction  of  the  vaginal  canal 
higher  up  as  well  as  at  the  vaginal  aperture. 

With  respect  to  the  merits  of  these  various  operations, 
much  will  depend  on  the  case  itself.  A  simple  perineal 
operation  is  sometimes  quite  sufficient  when  the  vagina  has 
not  been  much  distended,  but  when  the  protruded  mass  is 
considerable  the  vagina  is  necessarily  much  stretched,  and 
simply  to  close  the  aperture  of  the  vagina  is  attended  with 
no  permanent  benefit.     Many  cases  require  a  sort  of  com- 


462  DISEASES   OF   WOMEN. 

bined  operation,  a  restoration  of  the  perineum  and  a  nar- 
rowing of  the  canal  itself  for  some  little  distance  upward. 

The  Perineal  Operation. — It  may  be  well  in  this  place  to 
consider  the  treatment  of  ruptured  perineum  in  its  entirety, 
including  recent  as  well  as  chronic  cases. 

When  the  perineum  is  torn  in  the  process  of  labor,  the 
rent  extends  to  a  variable  depth  backward,  sometimes  de- 
stroying the  whole  sphincter  of  the  rectum,  in  other  cases 
not  affecting  the  sphincter  at  all,  but  subtracting  little  or 
much  from  the  perineum.  If  the  rent  looked  at  immedi- 
ately after  the  labor  is  over  exceeds  an  inch  in  depth,  it  may 
be  said  to  be  a  case  for  operation.  By  "immediately"  is 
meant  in  this  place  a  few  minutes  after  the  birth  of  the 
child,  at  the  time  the  parts  are  customarily  inspected.  Some 
days  later  a  rent  one  inch  in  depth  originally  will  have  be- 
come diminished — even  in  cases  when  no  union  has  occurred 
— very  materially.  And  what  has  appeared  a  rather  large 
rent  perhaps  is  then  found  to  be  comparatively  trifling. 
When  the  rent  is  at  all  considerable,  however,  the  operation 
is  required. 

The  primary  operation  should  be  performed  within  one 
hour  from  the  birth,  while  the  surfaces  are  still  raw  and 
bleeding.  The  surfaces  are  generally  very  well  secured  in 
apposition  by  rather  deeply  applied  silver-wire  sutures: 
two  or  more  may  be  required.  I  have  found  them  most 
easily  introduced  by  means  of  a  needle  two  and  a  half  inches 
long,  and  bent  into  a  completely  semicircular  shape.  Such 
a  needle  can  be  employed  with  the  patient  lying  on  her  side 
in  the  ordinary  obstetric  position.  The  sutures  should  go 
to  the  bottom  of  the  wound,  and  they  should  come  out  on 
the  surface  some  way  from  the  edges.  So  performed,  the 
operation  is  very  simple.  The  nurse  carefully  and  fre- 
quently dries  the  parts  with  soft  lint,  not  using  water,  the 
knees  are  tied  together,  the  catheter  is  employed,  the  bowels 
not  allowed  to  act  for  at  least  three  days,  and  on  the  fourth 
or  fifth  day  the  sutures  can  be  removed.  The  result  is  gen- 
erally very  satisfactory.  It  is  quite  true  that  by  rest  and 
position  union  will  sometimes  occur  without  use  of  sutures, 
but  this  result  cannot  be  depended  upon,  and  the  primary 
operation  is  so  little  troublesome  or  painful  to  the  patient, 
that  unless  the  rent  is  very  slight,  it  is  best  so  to  perform 
it.  It  is  of  very  little  use  inserting  sutures  when  the  labor 
has  been  over  some  hours;  union  rarely  then  occurs. 

The  secondary  operation  (a)  should  not  be  performed  until 


PROLAPSUS   OF   THE    UTERUS. 


463 


at  least  one  month  after  the  labor.  Careful  inspection  of 
the  parts  is  required  to  determine  on  the  line  of  procedure. 
Good  health,  avoidance  of  erysipelatous  influences,  a  dry, 
well-ventilated  room,  are  essentials  to  success.  The  bowels 
should  be  previously  carefully  evacuated.  Dr.  Thomas 
very  properly  insists  on  the  necessity  for  use  of  aperient 
medicine  for  some  days  previous  to  the  operation,  in  order 
to  dislodge  any  possible  accumulations,  but  it  is  best,  I 
consider,  to  use  injections  and  not  medicine  during  the  two 
days  preceding  the  operation.  In  long-standing  cases  of 
prolapsus,  complete  rest  in  bed  for  some  days  is  quite  requi- 
site, and  all  ulcerative  processes  should  have  ceased.     The 


Fig.   140. 


hairs  near  the  part  to  be  operated  on  are  first  removed  by 
a  razor,  the  patient  having  been  placed  in  the  lithotomy  po- 
sition at  the  edge  of  the  table.  A  semilunar  incision  is 
first  made  corresponding  to  the  edge  of  the  perineum,  and 
indicating  the  outer  edge  of  the  surfaces  to  be  bared.  A 
corresponding  internal  semilunar  incision  is  next  made 
within,  as  shown  in  the  annexed  figure  (Fig.  139);  and  the 
internal  and  external  lines  of  incision  connected  by  two 
horizontal  cuts.  The  strip  of  mucous  membrane  enclosed 
is  then  removed  by  the  scalpel  or  scissors.  Some  operators 
prefer  the  scissors,  as  the  bleeding  is  less.  The  extent  of 
this  surface  so  removed  varies  in  different  cases.     It  should 


*  Fig.  139  shows  the  shape  of  the  raw  surface  in  ordinary  cases.     The 
dotted  lines  indicate  the  position  of  the  hidden  deep  wire  sutures. 


464  DISEASES   OF  WOMEN. 

always  be  deeper  in  the  middle  line  (the  floor  of  the  vagina) 
than  at  the  two  extremities  of  the  horns  of  the  crescent; 
from  one  inch  to  an  inch  and  a  half  in  width  is  required  in 
the  middle  line.  The  opposite  sides,  thus  rendered  raw, 
are  next  brought  together  b}^  deeply  inserted  sutures.  The 
quill  suture,  or  modifications  of  it,  were  formerly  employed. 
I  have  used  for  some  time  past  beads  made  of  ebonite,  and 
of  such  a  form  as  to  allow  of  the  wire  used  being  easily 
attached  to  them  (see  Fig.  140).  They  are  little  balls  with 
a  projecting  neck,  and  perforated  through  the  middle. 
They  possess  the  great  advantage  of  permitting  any  easy 
regulation  of  the  tightness  of  the  suture,  and  allow  of  a 
better  circulation  in  the  soft  tissues  implicated.  The  quill 
suture  is  apt  to  give  rise  to  great  swelling  and  even  slough- 
ing of  the  new  perineum;  but  I  have  never  seen  this  hap- 
pen with  the  bead  suture.  The  deep  sutures,  two  or  three 
in  number,  are  inserted  at  a  distance  of  about  three  quarters 
of  an  inch  from  the  edge,  and  the  needle  carrying  the  suture 
should  so  pass  as  not  to  be  visible  initil  it  emerges  on  the  skin  on 
the  opposite  side.  One  of  the  sutures  at  least  should  pass  as 
deeply  as  this.  When  the  deep  sutures  are  inserted,  they 
should  be  temporarily  tightened  in  order  that  it  may  be 
ascertained  by  the  touch  internally  that  the  internal  edges 
are  really  in  apposition,  otherwise  gaping  results,  and 
union  will  not  occur.  Failing  this,  the  deeper  ones  must 
be  re-inserted.  The  finger  should  be  inserted  in  the  rectum 
in  order  to  be  sure  that  the  suture  does  not  enter  this 
canal.  Rather  stout  silver  wire  is,  I  consider,  preferable, 
and  the  needle  used  must  be  a  perforated  one,  having  a 
nearly  semicircular  large  sweep,  and  a  large  firm  handle.  It 
is  rather  more  difficult  to  pass  such  a  needle  through,  but 
the  purchase  thus  obtained  is  more  perfect.  The  ends  of 
the  wire  are  readily  secured  to  the  perforated  beads. 
When  the  deep  sutures  have  been  fixed,  two  or  three  super- 
ficial ones  are  generally  requisite,  for  which  a  smaller  wire 
serves  best.  The  knees  are  then  tied  together,  and  the 
patient  removed  to  bed.  In  my  opinion  the  best  after- 
treatment  of  the  wound  is  to  use  no  water,  but  simply  a 
piece  of  dry  lint  for  the  purpose  of  drying  the  surface, 
which  latter  should  be  done  frequently.  Position  on  the 
side,  but  the  side  may  be  changed  from  time  to  time.  The 
deep  sutures  to  be  loosened  or  removed  at  the  end  of  three 
days,  the  superficial  ones  rather  later.  As  regards  the  ma- 
terial for  the  sutures,  silk  or  catgut  are  preferred  by  some 


PROLAPSUS   OF  THE   UTERUS.  465 

operators  to  silver  wire.  Dr.  Granville  Bantock  prefers 
silkworm  gut,  and  he  employs  no  beads  or  other  appliances 
externally,  simply  knotting  the  sutures  in  the  middle  line. 
Dr.  Chambers  uses  wire,  fastening  the  wire  in  the  middle 
line  by  means  of  Aveling's  coil  and  shot. 

It  was  formerly  the  practice  to  give  opium  for  some  days, 
to  prevent  action  of  the  bowels,  but  some  operators — Dr. 
Bantock  for  instance — prefer  to  evacuate  the  rectum  after 
two  days  by  means  of  an  injection  of  olive  oil.  This  should 
be  carefully  injected  by  means  of  a  small  tube,  or  mischief 
may  be  done.  If  the  operation  is  simply  a  restoration  of 
the  perineum,  without  involving  the  rectal  sphincter,  the 
difficulty  of  procuring  an  evacuation  without  interference 
with  the  reparative  process  is  much  less  considerable.  The 
use  of  the  catheter  for  the  first  three  days  was  considered 
essential,  but  it  is  now  frequently  dispensed  with. 

The  combined  operation  (b),  consisting  of  constriction  of  the 
vaginal  canal  as  well  as  its  lower  aperture,  I  have  practiced 
in  the  following  manner:  One  plan  is  to  remove  a  triangu- 
lar strip  of  mucous  membrane  about  two  inches  broad  below, 
and  about  half  an  inch  broad  above,  from  the  floor  of  the 
vagina,  the  upper  end  or  apex  of  the  triangle  being  quite 
close  to  the  os  uteri.  The  ordinary  operation  (a)  is  then 
performed  as  described  above.  The  shape  of  the  surface 
thus  bared  is  shown  in  the  annexed  drawing  (Fig.  141). 
Another  plan  is  to  remove  two  triangular  strips  from  the 
vaginal  canal,  one  on  each  side  of  the  floor  of  the  vagina, 
the  operation  (a)  being  superadded.  When  the  edges  of 
these  triangular  bared  spots  are  brought  together,  the  va- 
gina is  of  course  proportionately  constricted.  The  method 
which  I  have  pursued  of  maintaining  the  edges  in  apposi- 
tion is  to  use  a  stout  piece  of  silver  wire.  By  means  of  a 
short  curved  needle,  such  as  is  used  in  vesico-vaginal  fistula 
cases,  the  stitch  used  d^iX-^x post-mortem  examinations  is  em- 
ployed to  bring  the  edges  together,  beginning  from  above. 
As  the  wire  is  drawn  through  it  is  straightened,  and  finally 
constitutes  a  kind  of  splint.  In  Fig.  141  the  arrangement 
of  the  suture  is  shown  before  the  wire  is  pulled  straight. 
The  upper  end  of  the  wire,  which  is  close  to  the  os  uteri,  is 
turned  downward  to  prevent  its  scratching,  and  cut  off 
short;  the  lower  end  projects  at  the  perineum,  and  is  twisted 
round  one  of  the  beads  when  the  operation  is  completed. 
This  splint-stitch,  as  it  may  be  termed,  answers  very  well; 
healing  generally  occurs,  and  the  wire,  having  done    its 


466 


DISEASES   OF   WOMEN. 


work,  comes  away  in  four  or  five  days  without  trouble  or 
necessity  for  stretching  tlie  perineal  wound.  If  two  tri- 
angular strips  are  removed,  the  same  procedure  is  adopted 
with  each  of  them.  This  combined  operation  at  once  re- 
stores tlie  perineum  and  removes  the  superabundant  and 
hypertrophied  vaginal  walls.*  The  two  operations  may  be 
readily  performed  at  one  and  the  same  time. 

Dr.  Savage  describes  a  method  of  operating  which  sub- 
stantially much   resembles    the    above.      He   extends    the 

Fig.  141. 


perineal  operation  by  removing  the  mucous  membrane  up- 
ward along  the  floor  of  the  vagina,  but  he  relies  on  deep 
sutures  for  producing  coaptation.  Such  coaptation  along 
this  internal  line  can  only  be  produced  by  the  deep  sutures 
at  the  cost  of  shortening  the  vagina  altogether.  Such 
shortening,  inasmuch  as  it  implies  descent  of  the  uterus,  I 
consider  objectionable,  and  therefore  the  use  of  separate 
sutures  for  the  vaginal  floor  are  to  be  preferred.     I  have 

*  This  method  of  constricting  the  vagina  was  first  described  by  me  in 
the  Lancet,  June  5,  1869. 


PROLAPSUS   OF  THE   UTERUS.  *         467 

performed  the  above  combined  operation  in  several  cases, 
and  find  it  a  satisfactory  one,  and  I  know  that  it  has  been 
performed  and  found  satisfactory  by  others.  The  plan  of 
extending  denudation  along  the  floor  of  the  vagina  in  form 
of  a  triangle,  as  in  the  above  operation,  has  been  also 
practiced  by  the  late  Professor  Simon  and  others  under  the 
term  "  posterior  colporrhaphy;"  the  edges  being,  however, 
approximated  by  ordinary  stitches. 

Another  method  of  narrowing  the  vagina   in  the   same 
part  is  that  of  Bischoff  of  Basle,  described  by  H.  Banga* 

Fig.  142. 


of  Chicago,  the  effect  of  which  is  that  the  lower  part  of  the 
vagina  is  not  only  narrowed,  but,  owing  to  the  elongation 
of  the  perineum,  its  axis  is  brought  forward.  A  tongue- 
shaped  flap  is  separated  in  the  direction  upward,  and  each 
edge  of  it  is  united  by  sutures  to  the  posterior  edge  of 
the  ordinary  lateral  denudation.  The  procedure  is  very 
ingenious.  Banga  states  that  since  1875  forty  such  opera- 
tions have  been  performed  by  Bischoff,  Engli,  and  Banga, 
with  only  one  death,  and  that  when  amputation  of  the  cer- 
vix was  also  performed. 

*  Amer.  Journ.  of  Obst.,  vol.  xi.,  p.  247. 


468 


DISEASES   OF  WOMEN. 


Operation  for  constricting  the  Upper  Part  of  the  Vagina.-^ 
Dr.  Marion  Sims*  describes  tliis  operation  as  follows:  The 
operation  consists  in  removing  a  V-shaped  piece  of  the 
mucous  membrane  forming  the  roof  of  the  vagina,  and 
therefore  covering  the  bladder.  The  apex  of  the  V  is  near 
the  urethra,  and  the  two  arms  reach  to  the  side  of  the  cer- 
vix uteri.  Finally,  the  shape  of  the  excised  surface  is  that 
represented  in  Fig.  142.  The  opposite  denuded  surfaces 
are  next  brought  togetiier  by  means  of  sutures,  a  X.o  b,  c  to 

Fig.  143. 


\= 


Fig.  144. 


Fig.  145. 


d.  The  effect  is,  tnat  the  vagina  has  its  canal  much  con- 
tracted; a  little  pouch  is  left  opening  at  e  (into  which  the 
uterine  cervix  might  slip  if  the  opening  be  left  too  large, 
as  in  cases  reported  by  Dr.  Emmet)  for  escape  of  the  secre- 
tions of  the  part.  Dr.  Sims  advises  that,  subsequently  to 
the  operation,  the  patient  be  kept  in  bed,  or  in  the  recum- 
bent position,  for  two  or  three  weeks,  the  bowels  to  be  con- 
fined for  a  week,  the  catheter  to  be  used.  The  lower 
sutures  are  removed  in  eight  or  ten  days,  the  upper  ones  in 
a  fortnight.     The  principle  of  Dr.  Sims's  operation   is   to 


Op.  cit.,  p.  310. 


PROLAPSUS  OF  THE  UTERUS.  469 

constrict  the  vagina   superiorly,    and    the    constriction    is 
effected  by  removing  part  of  tlie  roof  of  the  vagina. 

Perineal  Rupture  with  Destructio-  of  the  Rectal  Sphincter. — 
In  cases  where  the  sphincter  ani  is  entirely  destroyed  the 
difficulty  in  restoring  the  integrity  of  the  parts  is  very 
great.  Dr.  Emmet  in  1S73  published  the  results  of  his  ex- 
perience as  to  the  best  method  of  dealing  with  such  cases.* 
He  points  out  that  the  fibres  of  the  severed  muscle  are  in  a 
state  of  retraction,  those  which  formed  the  inner  surface  of 
the  circle  being  more  retracted  than  the  others;  the  result 
being  that  a  convex  surface  is  presented  at  the  floor  of  the 
rent.  It  is  necessary  to  denude  the  surface  on  each  side  far- 
ther back  than  at  first  sight  seems  necessary.  The  diagram 
(Fig.  143)  shows  the  retraction  of  the  fibres  after  rupture. 
The  suture  a  b  will,  Emmet  points  out,  only  imperfectly 
bring  the  parts  together;  Fig.  144  shows  the  action  of  the 
suture.  It  is  necessary  to  introduce  a  suture  at  a  lower 
level,  as  at  c  d;  and  the  action  of  tliis  suture  is  shown  in  Fig. 
145.  The  suture  c  d  is  first  secured,  the  bowels  are  re- 
lieved on  the  sixth  day  by  castor-oil,  the  sutures  being  re- 
moved the  day  after.  Dr.  Emmet  has  exhibited  great  in- 
genuity in  detecting  and  in  surmounting  what  had  before 
seemed  a  great  difficulty,  and  any  one  who  has  attempted 
the  operation  will  appreciate  the  truth  of  this. 

Mr.  Lawson  Tait  practices  an  operation  for  the  cure  of 
severe  perineal  rupture  coupled  with  laceration  of  the 
spliincter.f  He  denudes  the  surfaces  in  a  peculiar  way  by 
cutting  into  the  tissues  along  the  line  of  the  laceration  to 
a  certain  depth,  and  then  opening  out  the  raw  surfaces  thus 
produced  and  bringing  those  of  the  two  opposite  sides 
together  by  sutures,  which  are  so  introduced  as  to  bring 
the  deep  angles  of  the  incisions  into  approximation.  The 
innermost  of  the  sutures  are  in  the  vagina,  the  outermost 
are  on  the  perineal  surface. 

*  Latest  particulars  in  his  2d  edit.,  18S0,  p.  402. 
f  "  Obst.  Trans.,"  vol.  xxl.,  p.  292. 


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